Provider Demographics
NPI:1407533193
Name:WACHARA, JANE MUGENDITSA (RN)
Entity type:Individual
Prefix:MRS
First Name:JANE
Middle Name:MUGENDITSA
Last Name:WACHARA
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 GOLDEN SPRINGS DR UNIT E
Mailing Address - Street 2:
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-1458
Mailing Address - Country:US
Mailing Address - Phone:859-803-7779
Mailing Address - Fax:
Practice Address - Street 1:500 GOLDEN SPRINGS DR UNIT E
Practice Address - Street 2:
Practice Address - City:DIAMOND BAR
Practice Address - State:CA
Practice Address - Zip Code:91765-1458
Practice Address - Country:US
Practice Address - Phone:859-803-7779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-03
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95340030163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse