Provider Demographics
NPI:1003520677
Name:WIGGINS, COURTNEY
Entity Type:Individual
Prefix:MS
First Name:COURTNEY
Middle Name:
Last Name:WIGGINS
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 1:3200 ECHODALE AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21214-2619
Mailing Address - Country:US
Mailing Address - Phone:202-870-2916
Mailing Address - Fax:
Practice Address - Street 1:3200 ECHODALE AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21214-2619
Practice Address - Country:US
Practice Address - Phone:202-870-2916
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-09
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAL-00114310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility