Provider Demographics
NPI:1659872745
Name:WILSON, WANDA YVETTE
Entity type:Individual
Prefix:
First Name:WANDA
Middle Name:YVETTE
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 OFFICE SQUARE LN STE 201B
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-3663
Mailing Address - Country:US
Mailing Address - Phone:757-502-8980
Mailing Address - Fax:757-502-8989
Practice Address - Street 1:317 OFFICE SQUARE LN STE 201B
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-3663
Practice Address - Country:US
Practice Address - Phone:757-502-8980
Practice Address - Fax:757-502-8989
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-23
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA823988446Medicaid