MEDICARE: WILDA FAYE WADE PH.D.,RD, LDN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	L001066	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	14306	OTHER	NC	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1609086511
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WILDA FAYE WADE PH.D.,RD, LDN

Provider Business Mailing Address
First Line	:	2007 YANCEYVILLE ST # 91
Second Line	:	SUITE 407
City	:	GREENSBORO
State	:	NC
Zip	:	27405-5000
Country	:	US
Telephone Number	:	336-339-2748
Fax Number	:

Provider Business Practice Location Address
First Line	:	2007 YANCEYVILLE ST # 91
Second Line	:	SUITE 407
City	:	GREENSBORO
State	:	NC
Zip	:	27405-5000
Country	:	US
Telephone Number	:	336-542-5545
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/23/2007
Last Update Date	:	03/17/2008

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