Healthcare Provider Details

I. General information

NPI: 1982127247
Provider Name (Legal Business Name): KATY MARIE JACKSON WIGGINS REGISTERED NURSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2017
Last Update Date: 07/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12801 IRON BRIDGE RD
CHESTER VA
23831-1669
US

IV. Provider business mailing address

9309 POLE RUN RD
DISPUTANTA VA
23842-5524
US

V. Phone/Fax

Practice location:
  • Phone: 804-748-9071
  • Fax:
Mailing address:
  • Phone: 804-712-0855
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1600X
TaxonomyContinuing Education/Staff Development Registered Nurse
License Number0001222327
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: