Provider Demographics
NPI:1164106779
Name:BERARDUCCI, WALLANDA W
Entity Type:Individual
Prefix:
First Name:WALLANDA
Middle Name:W
Last Name:BERARDUCCI
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 1:6420 OLD US 31 S
Mailing Address - Street 2:
Mailing Address - City:CHARLEVOIX
Mailing Address - State:MI
Mailing Address - Zip Code:49720-8918
Mailing Address - Country:US
Mailing Address - Phone:231-675-7004
Mailing Address - Fax:
Practice Address - Street 1:6420 OLD US 31 S
Practice Address - Street 2:
Practice Address - City:CHARLEVOIX
Practice Address - State:MI
Practice Address - Zip Code:49720-8918
Practice Address - Country:US
Practice Address - Phone:231-675-7004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-14
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula