Healthcare Provider Details

I. General information

NPI: 1790320919
Provider Name (Legal Business Name): ROSALIE DAWN WILEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/12/2019
Last Update Date: 10/30/2025
Certification Date: 10/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 BAILEY AVE STE 2
NEEDLES CA
92363-3105
US

IV. Provider business mailing address

1600 BAILEY AVE STE 2
NEEDLES CA
92363-3105
US

V. Phone/Fax

Practice location:
  • Phone: 760-326-9313
  • Fax: 760-326-2864
Mailing address:
  • Phone: 760-326-9313
  • Fax: 760-326-2864

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: