=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790289858
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MRS. NANCY WEAKLEY WANNER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/22/2018
-----------------------------------------------------
Last Update Date | 06/16/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 75 MONCURE LN
-----------------------------------------------------
City | STAFFORD
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22556-4621
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-658-6300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1011 ATLANTIC DR
-----------------------------------------------------
City | STAFFORD
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22554-2107
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-659-9384
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 2202001267
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------