MEDICARE: WANDA MAYBERRY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD1600X	Developmental Disabilities Clinic/Center

General Provider Information

NPI Number	:	1497206189
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WANDA MAYBERRY

Provider Business Mailing Address
First Line	:	PO BOX 82
Second Line	:
City	:	KEYSTONE HEIGHTS
State	:	FL
Zip	:	32656-0082
Country	:	US
Telephone Number	:	352-448-9843
Fax Number	:	888-213-4424

Provider Business Practice Location Address
First Line	:	1445 S LAWRENCE BLVD
Second Line	:
City	:	KEYSTONE HEIGHTS
State	:	FL
Zip	:	32656-9349
Country	:	US
Telephone Number	:	352-448-9843
Fax Number	:	888-213-4424

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/18/2016
Last Update Date	:	11/02/2016

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Directions to “ WANDA MAYBERRY ” Practice Location

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