Healthcare Provider Details

I. General information

NPI: 1336254648
Provider Name (Legal Business Name): WANDA LISA STREET APRN-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: WANDA LISA MONROIG

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 12/29/2022
Certification Date: 12/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6600 VAN AALST BLVD
FORT BENNING GA
31905-2102
US

IV. Provider business mailing address

1654 OSSAHATCHIE CREEK RD
ELLERSLIE GA
31807-5342
US

V. Phone/Fax

Practice location:
  • Phone: 706-544-8688
  • Fax:
Mailing address:
  • Phone: 706-582-3575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License NumberRN140175
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN140175
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: