Provider Demographics
NPI:1104291426
Name:WAKEFIELD, MARK (RN)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:WAKEFIELD
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4022 VIA ALDEA
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92057-6432
Mailing Address - Country:US
Mailing Address - Phone:760-453-2526
Mailing Address - Fax:
Practice Address - Street 1:1738 S TREMONT ST
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92054-5309
Practice Address - Country:US
Practice Address - Phone:760-439-2800
Practice Address - Fax:760-433-5031
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-11
Last Update Date:2015-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA525200163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse