Provider Demographics
NPI:1144765306
Name:WADDY, MICHELLE DELORIS
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:DELORIS
Last Name:WADDY
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:PO BOX 4410
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23058-4410
Mailing Address - Country:US
Mailing Address - Phone:804-939-2564
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 4410
Practice Address - Street 2:
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23058-4410
Practice Address - Country:US
Practice Address - Phone:804-939-2564
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-27
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA471884853247000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247000000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Health Information