Provider Demographics
NPI:1801244389
Name:WENDTLAND, COLLEEN (CPED, CFOM)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:WENDTLAND
Suffix:
Gender:F
Credentials:CPED, CFOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1468 PEPPER LN
Mailing Address - Street 2:
Mailing Address - City:BANNING
Mailing Address - State:CA
Mailing Address - Zip Code:92220-1469
Mailing Address - Country:US
Mailing Address - Phone:909-553-0646
Mailing Address - Fax:
Practice Address - Street 1:1468 PEPPER LN
Practice Address - Street 2:
Practice Address - City:BANNING
Practice Address - State:CA
Practice Address - Zip Code:92220-1469
Practice Address - Country:US
Practice Address - Phone:909-553-0646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-25
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224L00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPedorthist
No224900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMastectomy Fitter
No225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter