=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417757535
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CAROLYNN WIMMER RN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/17/2025
-----------------------------------------------------
Last Update Date | 03/17/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9888 GENESEE AVE
-----------------------------------------------------
City | LA JOLLA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92037-1205
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-834-1798
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4225 AVATI DR
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92117-4408
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-690-5094
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WL0100X
-----------------------------------------------------
Taxonomy Name | Lactation Consultant (Registered Nurse)
-----------------------------------------------------
License Number | RN95225011
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 163WM0102X
-----------------------------------------------------
Taxonomy Name | Maternal Newborn Registered Nurse
-----------------------------------------------------
License Number | RN95225011
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------