Healthcare Provider Details

I. General information

NPI: 1366587206
Provider Name (Legal Business Name): CAROLYN JOYCE WADSWORTH NURSE PRACTITONER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/20/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

351 S HUDSON AVE
PASADENA CA
91101-3507
US

IV. Provider business mailing address

4082 DENVER AVE
YORBA LINDA CA
92886-1944
US

V. Phone/Fax

Practice location:
  • Phone: 626-795-6981
  • Fax: 626-584-1540
Mailing address:
  • Phone: 714-524-6756
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number245433
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: