Healthcare Provider Details

I. General information

NPI: 1487366472
Provider Name (Legal Business Name): RUTH WANDA WADE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/21/2022
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5939 REDDMAN RD
CHARLOTTE NC
28212-1654
US

IV. Provider business mailing address

4715 JACQUELYNE DR
INDIAN TRAIL NC
28079-9402
US

V. Phone/Fax

Practice location:
  • Phone: 704-703-6060
  • Fax:
Mailing address:
  • Phone: 561-967-5350
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5017652
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11023697
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: