=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760835342
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EMANUEL MONTEZ WADDELL
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/19/2016
-----------------------------------------------------
Last Update Date | 05/22/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 109 RAILROAD AVE
-----------------------------------------------------
City | WAKEFIELD
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23888-0097
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-312-8730
-----------------------------------------------------
Fax | 757-510-9326
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 109 RAILROAD AVE
-----------------------------------------------------
City | WAKEFIELD
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23888
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-312-8730
-----------------------------------------------------
Fax | 757-510-9326
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | AP138266
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 0024191239
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 790297
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------