Healthcare Provider Details

I. General information

NPI: 1225420284
Provider Name (Legal Business Name): JENNIFER J WANG CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2015
Last Update Date: 10/21/2024
Certification Date: 10/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3019 OCEAN PARK BLVD UNIT 358
SANTA MONICA CA
90405-3004
US

IV. Provider business mailing address

3019 OCEAN PARK BLVD UNIT 358
SANTA MONICA CA
90405-3004
US

V. Phone/Fax

Practice location:
  • Phone: 310-795-5988
  • Fax:
Mailing address:
  • Phone: 310-795-5988
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number105362
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: