Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 111N00000X | Chiropractor | DC22891 | CA |
Y | 111NI0013X | Independent Medical Examiner | DC22891 | CA |
N | 111NX0100X | Occupational Health | DC22891 | CA |
NPI | 1144597006 |
---|---|
Provider Name | Mrs. Mary Ellen Wiesenfarth Simone |
First Address | Covina, CA 91723-1516 |
Second Address | Covina, CA 91723-1516 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 21/11/2011 |
Last Update Date | 21/11/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
DC22891 | LICENSE (01) | CA |