Healthcare Provider Details

I. General information

NPI: 1205421310
Provider Name (Legal Business Name): ZONDRIA WADE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2021
Last Update Date: 03/02/2021
Certification Date: 03/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2817 LARKHALL RD
COLUMBIA SC
29223-2132
US

IV. Provider business mailing address

2817 LARKHALL RD
COLUMBIA SC
29223-2132
US

V. Phone/Fax

Practice location:
  • Phone: 252-532-3860
  • Fax:
Mailing address:
  • Phone: 252-532-3860
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH1000X
TaxonomyHospice Registered Nurse
License Number318421
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: