Healthcare Provider Details

I. General information

NPI: 1982752895
Provider Name (Legal Business Name): JUANITA WIELENGA CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 12/01/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 14TH ST SUITE #314
RIVERSIDE CA
92501-4083
US

IV. Provider business mailing address

4000 14TH ST SUITE #314
RIVERSIDE CA
92501-4083
US

V. Phone/Fax

Practice location:
  • Phone: 951-781-7140
  • Fax: 951-781-7184
Mailing address:
  • Phone: 951-781-7140
  • Fax: 951-781-7184

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberNMW1014
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: