Provider Demographics
NPI:1164078622
Name:MOULSON, WANDA KAY
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:KAY
Last Name:MOULSON
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 1:2713 DUNLIN DR
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29707-9118
Mailing Address - Country:US
Mailing Address - Phone:804-350-9162
Mailing Address - Fax:
Practice Address - Street 1:2713 DUNLIN DR
Practice Address - Street 2:
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29707-9118
Practice Address - Country:US
Practice Address - Phone:804-350-9162
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-12
Last Update Date:2019-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider