Healthcare Provider Details

I. General information

NPI: 1396942009
Provider Name (Legal Business Name): SUSAN WEBB WILD RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

780 SHADOWRIDGE DR KAISER DEPARTMENT OF PSYCHIATRY
VISTA CA
92083-7986
US

IV. Provider business mailing address

780 SHADOWRIDGE DR KAISER DEPARTMENT OF PSYCHIATRY
VISTA CA
92083-7986
US

V. Phone/Fax

Practice location:
  • Phone: 760-599-2350
  • Fax: 760-599-2399
Mailing address:
  • Phone: 760-599-2350
  • Fax: 760-599-2399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number338329
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: