Provider Demographics
NPI:1902935323
Name:WRINKLE, ALISA (LAC)
Entity Type:Individual
Prefix:
First Name:ALISA
Middle Name:
Last Name:WRINKLE
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7625 GREENLY DR
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94605-3012
Mailing Address - Country:US
Mailing Address - Phone:510-553-1334
Mailing Address - Fax:
Practice Address - Street 1:7625 GREENLY DR
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94605-3012
Practice Address - Country:US
Practice Address - Phone:510-553-1334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC6088171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist