Provider Demographics
NPI:1053012112
Name:EDQUIBAN, WRYONNA (CMPSS)
Entity type:Individual
Prefix:
First Name:WRYONNA
Middle Name:
Last Name:EDQUIBAN
Suffix:
Gender:
Credentials:CMPSS
Other - Prefix:
Other - First Name:REI
Other - Middle Name:
Other - Last Name:EDQUIBAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:730 MEDICAL CENTER CT
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91911-6618
Mailing Address - Country:US
Mailing Address - Phone:619-591-5740
Mailing Address - Fax:
Practice Address - Street 1:730 MEDICAL CENTER CT
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911-6618
Practice Address - Country:US
Practice Address - Phone:619-591-5740
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-15
Last Update Date:2025-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
CAMPSS-AFLSMU175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No172V00000XOther Service ProvidersCommunity Health Worker