Provider Demographics
NPI:1033694070
Name:MERRITT, WENDY LEE MARGARET
Entity type:Individual
Prefix:
First Name:WENDY
Middle Name:LEE MARGARET
Last Name:MERRITT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1310 RUSSELL ST
Mailing Address - Street 2:
Mailing Address - City:LA HABRA
Mailing Address - State:CA
Mailing Address - Zip Code:90631-2533
Mailing Address - Country:US
Mailing Address - Phone:267-436-3857
Mailing Address - Fax:
Practice Address - Street 1:1310 RUSSELL ST
Practice Address - Street 2:
Practice Address - City:LA HABRA
Practice Address - State:CA
Practice Address - Zip Code:90631-2533
Practice Address - Country:US
Practice Address - Phone:267-436-3857
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-25
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
369463069OtherTRICARE
3G18-JE7-UU45OtherMEDICARE