Healthcare Provider Details

I. General information

NPI: 1164416756
Provider Name (Legal Business Name): WANDA LAFAYE GHANT-MOONEY MSN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: WANDA LAFAYE GHANT

II. Dates (important events)

Enumeration Date: 09/09/2005
Last Update Date: 09/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8124 VETERANS HWY
MILLERSVILLE MD
21108
US

IV. Provider business mailing address

8124 VETERANS HWY
MILLERSVILLE MD
21108-1412
US

V. Phone/Fax

Practice location:
  • Phone: 866-389-2727
  • Fax: 401-216-3854
Mailing address:
  • Phone: 866-389-2727
  • Fax: 401-216-3854

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR124816
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: