Healthcare Provider Details

I. General information

NPI: 1033638333
Provider Name (Legal Business Name): WANDA RENEE YOUNG AGPCNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2017
Last Update Date: 09/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3295 FM 3514
BEAUMONT TX
77705-7655
US

IV. Provider business mailing address

10901 TELEPHONE RD APT 44
HOUSTON TX
77075-4646
US

V. Phone/Fax

Practice location:
  • Phone: 409-727-8400
  • Fax:
Mailing address:
  • Phone: 832-409-9771
  • Fax: 713-987-5454

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number544145
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: