Healthcare Provider Details

I. General information

NPI: 1619572153
Provider Name (Legal Business Name): TIERRA LATRICE WIGGINS APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2020
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5589 GREENWICH RD STE 100
VIRGINIA BEACH VA
23462-6565
US

IV. Provider business mailing address

NAVAL MEDICAL CENTER PORTSMOUTH 620 JOHN PAUL JONES CIRCLE
PORTSMOUTH VA
23708
US

V. Phone/Fax

Practice location:
  • Phone: 888-628-8272
  • Fax:
Mailing address:
  • Phone: 757-953-5397
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024180432
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number0024180432
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: