Provider Demographics
NPI:1003110776
Name:CALDWELL, WANDA B
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:B
Last Name:CALDWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1807
Mailing Address - Street 2:
Mailing Address - City:LEICESTER
Mailing Address - State:NC
Mailing Address - Zip Code:28748-1807
Mailing Address - Country:US
Mailing Address - Phone:828-645-3094
Mailing Address - Fax:
Practice Address - Street 1:30 MELODY ROSE LN
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28804-9612
Practice Address - Country:US
Practice Address - Phone:828-658-2633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-10
Last Update Date:2011-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCFCL-011-308310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC77-0667169Medicaid