Provider Demographics
NPI:1760376008
Name:WEATHERALL, JUSTIN
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:WEATHERALL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5739 CHESLEY AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90043-2423
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5739 CHESLEY AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90043-2423
Practice Address - Country:US
Practice Address - Phone:818-826-1296
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-03
Last Update Date:2025-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist