Healthcare Provider Details

I. General information

NPI: 1538436092
Provider Name (Legal Business Name): MARILYN WADE-FOSTER NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2011
Last Update Date: 02/24/2022
Certification Date: 02/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1291 S BOSTON RD
DANVILLE VA
24540-5032
US

IV. Provider business mailing address

2509 RICHARDSON DR STE A
REIDSVILLE NC
27320-5926
US

V. Phone/Fax

Practice location:
  • Phone: 434-228-7923
  • Fax:
Mailing address:
  • Phone: 336-347-7998
  • Fax: 336-347-7998

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number0024170261
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5005456
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: