Basic Information
| Provider Information | |||||||||
| NPI: | 1568120251 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DECENT | ||||||||
| FirstName: | WENDA | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | RN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DECENT | ||||||||
| OtherFirstName: | WENDA | ||||||||
| OtherMiddleName: | ELIZABETH | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1090 E CYPRESS AVE STE B | ||||||||
| Address2: | |||||||||
| City: | REDDING | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960021163 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5302232332 | ||||||||
| FaxNumber: | 5302234721 | ||||||||
| Practice Location | |||||||||
| Address1: | 1090 E CYPRESS AVE STE B | ||||||||
| Address2: | |||||||||
| City: | REDDING | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960021163 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5302232332 | ||||||||
| FaxNumber: | 5302234721 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2021 | ||||||||
| LastUpdateDate: | 11/30/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0808X | 627320 | CA | Y | Nursing Service Providers | Registered Nurse | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 823540239 | 05 | CA | MEDICAID |