Healthcare Provider Details

I. General information

NPI: 1619047032
Provider Name (Legal Business Name): MS. WANDA JANE PARKER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6209 SUNNYSIDE RD
CAPE CHARLES VA
23310
US

IV. Provider business mailing address

6209 SUNNYSIDE RD P.O. BOX 206
CAPE CHARLES VA
23310
US

V. Phone/Fax

Practice location:
  • Phone: 757-331-1780
  • Fax:
Mailing address:
  • Phone: 757-331-1780
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number0230008781
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: