Doctor Name: | JILL MARIE WAALEN |
NPI Number: | 1578611554 |
Entity Type Code: | Individual (1) |
Gender: | F |
Credentials: | MD |
License Number: | A69683 |
Business Practice Address: | 4405 Vandever Ave San Diego, CA - 921203315 |
Business Phone Number: | 6195285000 |
Business Fax Number: | |
Mailing Address: | 393 E Walnut St, 3rd Floor Phr Systems PASADENA |
State: | CA |
Postal Code: | 911880001 |
Phone Number: | 0000000000 |
Fax Number: | 0000000000 |
NPI Enumeration Date: | 01/08/2007 |
NPI Last Update Date: | 11/30/2007 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 208D00000X |
License Number: | A69683 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | CA |
Taxonomy Type: | Allopathic & Osteopathic Physicians |
Taxonomy Classification: | General Practice |
Taxonomy Specialization: | |
Taxonomy Definition: |