Provider Demographics
NPI:1164416756
Name:GHANT-MOONEY, WANDA LAFAYE (MSN)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:LAFAYE
Last Name:GHANT-MOONEY
Suffix:
Gender:F
Credentials:MSN
Other - Prefix:
Other - First Name:WANDA
Other - Middle Name:LAFAYE
Other - Last Name:GHANT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8124 VETERANS HWY
Mailing Address - Street 2:
Mailing Address - City:MILLERSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21108-1412
Mailing Address - Country:US
Mailing Address - Phone:866-389-2727
Mailing Address - Fax:401-216-3854
Practice Address - Street 1:8124 VETERANS HWY
Practice Address - Street 2:
Practice Address - City:MILLERSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21108
Practice Address - Country:US
Practice Address - Phone:866-389-2727
Practice Address - Fax:401-216-3854
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR124816363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
S84332Medicare UPIN
016577M72Medicare ID - Type Unspecified