MEDICARE: VIOLET WANNER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WN0002X	Neonatal Intensive Care Registered Nurse	104773	CO
2	363L00000X	Nurse Practitioner	95002866	CA

General Provider Information

NPI Number	:	1851713432
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VIOLET WANNER

Provider Business Mailing Address
First Line	:	5767 W CENTURY BLVD STE 400
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90045-5631
Country	:	US
Telephone Number	:	303-670-0647
Fax Number	:

Provider Business Practice Location Address
First Line	:	10833 LE CONTE AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90095-4492
Country	:	US
Telephone Number	:	310-825-0867
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/15/2014
Last Update Date	:	07/21/2022

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Directions to “ VIOLET WANNER ” Practice Location

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