Healthcare Provider Details

I. General information

NPI: 1104050491
Provider Name (Legal Business Name): WENDY ANN WIGMORE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2009
Last Update Date: 05/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

506 MAIN ST
VACAVILLE CA
95688-3922
US

IV. Provider business mailing address

506 MAIN ST
VACAVILLE CA
95688-3922
US

V. Phone/Fax

Practice location:
  • Phone: 707-446-7014
  • Fax: 707-446-1871
Mailing address:
  • Phone: 707-446-7014
  • Fax: 707-446-1871

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number103834
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: