1366940363 NPI number — WILHELMINA GERARDA VAN DAELEN-DENEN PT

Table of content: WILHELMINA GERARDA VAN DAELEN-DENEN PT (NPI 1366940363)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366940363 NPI number — WILHELMINA GERARDA VAN DAELEN-DENEN PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VAN DAELEN-DENEN
Provider First Name:
WILHELMINA
Provider Middle Name:
GERARDA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1366940363
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/25/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5769 ERLANGER ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92122-3801
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
858-558-7406
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3535 MANCHESTER AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CARDIFF BY THE SEA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92007-1520
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-436-8900
Provider Business Practice Location Address Fax Number:
760-436-0460
Provider Enumeration Date:
01/25/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT20037 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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