Basic Information
| Provider Information | |||||||||
| NPI: | 1326639964 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WASKET | ||||||||
| FirstName: | ANDRA | ||||||||
| MiddleName: | AMORY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 277 BLOOMINGTON AVE UNIT 235 | ||||||||
| Address2: | |||||||||
| City: | RIALTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923766495 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9092225967 | ||||||||
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| Practice Location | |||||||||
| Address1: | 14677 MERRILL AVE | ||||||||
| Address2: | |||||||||
| City: | FONTANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923354219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9516432340 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2021 | ||||||||
| LastUpdateDate: | 01/27/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 167G00000X | 41806 | CA | Y | Nursing Service Providers | Licensed Psychiatric Technician |
No ID Information.