=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801244389
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | COLLEEN WENDTLAND CPED, CFOM
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/25/2016
-----------------------------------------------------
Last Update Date | 05/25/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1468 PEPPER LN
-----------------------------------------------------
City | BANNING
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92220-1469
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-553-0646
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1468 PEPPER LN
-----------------------------------------------------
City | BANNING
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92220-1469
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-553-0646
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 224900000X
-----------------------------------------------------
Taxonomy Name | Mastectomy Fitter
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 224L00000X
-----------------------------------------------------
Taxonomy Name | Pedorthist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 225000000X
-----------------------------------------------------
Taxonomy Name | Orthotic Fitter
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------