Provider Demographics
NPI:1003415217
Name:MASSIE, WANDA S
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:S
Last Name:MASSIE
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 1:3081 CROSS RD
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:OH
Mailing Address - Zip Code:45697-9749
Mailing Address - Country:US
Mailing Address - Phone:937-217-3341
Mailing Address - Fax:
Practice Address - Street 1:3081 CROSS RD
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:OH
Practice Address - Zip Code:45697-9749
Practice Address - Country:US
Practice Address - Phone:937-217-3341
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-19
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No251X00000XAgenciesSupports Brokerage
No253Z00000XAgenciesIn Home Supportive Care
No347C00000XTransportation ServicesPrivate Vehicle
No376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0100750Medicaid