Provider Demographics
NPI:1114570470
Name:BRISBON, WANDA MARIE (RN)
Entity Type:Individual
Prefix:MRS
First Name:WANDA
Middle Name:MARIE
Last Name:BRISBON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:WANDA
Other - Middle Name:MARIE
Other - Last Name:BRISBON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:282 HAIGS CRK N
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:SC
Mailing Address - Zip Code:29045-8328
Mailing Address - Country:US
Mailing Address - Phone:803-606-8921
Mailing Address - Fax:
Practice Address - Street 1:6439 GARNERS FERRY RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29209-1638
Practice Address - Country:US
Practice Address - Phone:803-776-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-16
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC49769163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse