Basic Information
| Provider Information | |||||||||
| NPI: | 1043306707 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WIGHT | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | CALLIE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16111 PLUMMER ST | ||||||||
| Address2: | OOPW | ||||||||
| City: | SEPULVEDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913432036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188959555 | ||||||||
| FaxNumber: | 8188959453 | ||||||||
| Practice Location | |||||||||
| Address1: | 16111 PLUMMER ST | ||||||||
| Address2: | OOPW | ||||||||
| City: | SEPULVEDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913432036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188959555 | ||||||||
| FaxNumber: | 8188959453 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0808X | RN 262603 | CA | Y | Nursing Service Providers | Registered Nurse | Psych/Mental Health |
No ID Information.