Provider Demographics
NPI:1073785127
Name:EALEY, WANDA
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:
Last Name:EALEY
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 1:10804 BRIAR RD SW
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-2237
Mailing Address - Country:US
Mailing Address - Phone:253-589-1554
Mailing Address - Fax:
Practice Address - Street 1:10804 BRIAR RD SW
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-2237
Practice Address - Country:US
Practice Address - Phone:253-589-1554
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-28
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLPN0000049199164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse