Healthcare Provider Details

I. General information

NPI: 1023482627
Provider Name (Legal Business Name): JOANNA J WADE LNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/19/2015
Last Update Date: 09/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3505 WESTERN AVE STE A
KINGMAN AZ
86409-3074
US

IV. Provider business mailing address

600 JACKSON ST
FREDERICKSBURG VA
22401-5719
US

V. Phone/Fax

Practice location:
  • Phone: 928-757-8111
  • Fax: 928-757-1199
Mailing address:
  • Phone: 540-373-3223
  • Fax: 540-371-3753

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number0024173025
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP8810
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: