Provider Demographics
NPI:1073747820
Name:WAHDAN, LAILA (DACCHM, MTCM, LAC)
Entity type:Individual
Prefix:
First Name:LAILA
Middle Name:
Last Name:WAHDAN
Suffix:
Gender:F
Credentials:DACCHM, MTCM, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5245 W PIAFFE ST
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-7481
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:951 E PLAZA DR STE 120
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6567
Practice Address - Country:US
Practice Address - Phone:408-761-0006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-07
Last Update Date:2025-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12924171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist