Provider Demographics
NPI:1366587206
Name:WADSWORTH, CAROLYN JOYCE (NURSE PRACTITONER)
Entity type:Individual
Prefix:MRS
First Name:CAROLYN
Middle Name:JOYCE
Last Name:WADSWORTH
Suffix:
Gender:F
Credentials:NURSE PRACTITONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4082 DENVER AVE
Mailing Address - Street 2:
Mailing Address - City:YORBA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92886-1944
Mailing Address - Country:US
Mailing Address - Phone:714-524-6756
Mailing Address - Fax:
Practice Address - Street 1:351 S HUDSON AVE
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-3507
Practice Address - Country:US
Practice Address - Phone:626-795-6981
Practice Address - Fax:626-584-1540
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA245433363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASS1964881Medicaid