Provider Demographics
NPI:1154190163
Name:WILSON, JOANNA MICHELLE
Entity type:Individual
Prefix:MRS
First Name:JOANNA
Middle Name:MICHELLE
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:JOANNA
Other - Middle Name:MICHELLE
Other - Last Name:FUENTES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:530 W BADILLO ST
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91722-3762
Mailing Address - Country:US
Mailing Address - Phone:626-993-3000
Mailing Address - Fax:
Practice Address - Street 1:530 W BADILLO ST
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91722-3762
Practice Address - Country:US
Practice Address - Phone:626-993-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-02
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program