Basic Information
Provider Information | |||||||||
NPI: | 1093913121 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WALKER | ||||||||
FirstName: | LENA | ||||||||
MiddleName: | M | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | STUDENT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WALKER | ||||||||
OtherFirstName: | LENA | ||||||||
OtherMiddleName: | M | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 831 E ARROW HWY | ||||||||
Address2: |   | ||||||||
City: | POMONA | ||||||||
State: | CA | ||||||||
PostalCode: | 917672535 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9093984383 | ||||||||
FaxNumber: | 9093980127 | ||||||||
Practice Location | |||||||||
Address1: | 831 E ARROW HWY | ||||||||
Address2: |   | ||||||||
City: | POMONA | ||||||||
State: | CA | ||||||||
PostalCode: | 917672535 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9093984383 | ||||||||
FaxNumber: | 9093980127 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/10/2007 | ||||||||
LastUpdateDate: | 07/10/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1744R1102X | 190101 | CA | Y |   | Other Service Providers | Specialist | Research Study |
ID Information
ID | Type | State | Issuer | Description | 3249 | 01 |   | CAS NUMBER | OTHER | 190101 | 01 | CA | PROVIDERS NUMBER | OTHER |