Healthcare Provider Details

I. General information

NPI: 1235951765
Provider Name (Legal Business Name): IRIE WONDER WOODS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2024
Last Update Date: 10/28/2024
Certification Date: 10/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

457 ESPERANZA WAY
STOCKTON CA
95207-2210
US

IV. Provider business mailing address

457 ESPERANZA WAY
STOCKTON CA
95207-2210
US

V. Phone/Fax

Practice location:
  • Phone: 209-787-9420
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: