Healthcare Provider Details

I. General information

NPI: 1770926594
Provider Name (Legal Business Name): LISA MARIE WHEADON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2013
Last Update Date: 02/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 N ROSE DR SUITE 210
PLACENTIA CA
92870-3840
US

IV. Provider business mailing address

1325 N ROSE DR SUITE 210
PLACENTIA CA
92870-3840
US

V. Phone/Fax

Practice location:
  • Phone: 714-961-5804
  • Fax: 657-258-0314
Mailing address:
  • Phone: 714-961-5804
  • Fax: 657-258-0314

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number20921
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: