Basic Information
| Provider Information | |||||||||
| NPI: | 1952714347 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WUNDER | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | RENEE | ||||||||
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| Credential: | LVN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20739 LYCOMING ST SPC 22 | ||||||||
| Address2: | |||||||||
| City: | DIAMOND BAR | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917897322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9097539807 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 801 E CHAPMAN AVE | ||||||||
| Address2: | #203 | ||||||||
| City: | FULLERTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928313839 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7146808268 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2014 | ||||||||
| LastUpdateDate: | 06/04/2014 | ||||||||
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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 | 164X00000X | 255724 | CA | Y | Nursing Service Providers | Licensed Vocational Nurse |
No ID Information.