Provider Demographics
NPI:1093480840
Name:WHIDDON, WANDA LYNN
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:LYNN
Last Name:WHIDDON
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 1:5750A SOUTHLAND DR
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36693-3316
Mailing Address - Country:US
Mailing Address - Phone:251-450-5916
Mailing Address - Fax:251-302-7453
Practice Address - Street 1:1015 MONTLIMAR DR
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36609-1713
Practice Address - Country:US
Practice Address - Phone:251-450-2250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-13
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-104464363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health