Healthcare Provider Details

I. General information

NPI: 1821053422
Provider Name (Legal Business Name): JOANNE RUE WUNDERLICH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2006
Last Update Date: 06/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 COMMERCIAL LN SUITE 220
SUFFOLK VA
23434-8149
US

IV. Provider business mailing address

1005 COMMERCIAL LN SUITE 220
SUFFOLK VA
23434-8149
US

V. Phone/Fax

Practice location:
  • Phone: 757-668-2600
  • Fax: 757-668-2620
Mailing address:
  • Phone: 757-668-2600
  • Fax: 757-668-2620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101052372
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: