Healthcare Provider Details

I. General information

NPI: 1336794049
Provider Name (Legal Business Name): MICHELLE D WADE AGACNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2019
Last Update Date: 11/30/2021
Certification Date: 11/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 IRVING ST NW
WASHINGTON DC
20010-2921
US

IV. Provider business mailing address

4681 DESERT RD
SUFFOLK VA
23434-7965
US

V. Phone/Fax

Practice location:
  • Phone: 202-877-7445
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN1048132
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: