Provider Demographics
NPI:1033517156
Name:ANDERSON, WANDA
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:
Last Name:ANDERSON
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 1:3405 SWEETWATER RD
Mailing Address - Street 2:APT 915
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044-2445
Mailing Address - Country:US
Mailing Address - Phone:678-431-8389
Mailing Address - Fax:
Practice Address - Street 1:3783 PRESIDENTIAL PKWY
Practice Address - Street 2:SUITE 142 I
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30340-3709
Practice Address - Country:US
Practice Address - Phone:678-431-8389
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-06
Last Update Date:2014-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies