Healthcare Provider Details

I. General information

NPI: 1629306139
Provider Name (Legal Business Name): MARSHALL ROMONA WIGFALL DNP, FNP, PMH-NP/CNS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2009
Last Update Date: 04/20/2022
Certification Date: 04/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 HUGUENOT RD STE E
MIDLOTHIAN VA
23113-2397
US

IV. Provider business mailing address

PO BOX 1556
MIDLOTHIAN VA
23113-1556
US

V. Phone/Fax

Practice location:
  • Phone: 804-594-6837
  • Fax: 804-621-2248
Mailing address:
  • Phone: 804-594-6837
  • Fax: 804-621-2248

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number0001190712
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License Number0015000882
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number0024168559
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: