Provider Demographics
NPI:1225524671
Name:WADE, JEVETTA R
Entity Type:Individual
Prefix:
First Name:JEVETTA
Middle Name:R
Last Name:WADE
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 49329
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-0077
Mailing Address - Country:US
Mailing Address - Phone:980-833-2029
Mailing Address - Fax:980-545-4415
Practice Address - Street 1:8828 BALMORAL PARK DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-1338
Practice Address - Country:US
Practice Address - Phone:980-833-2029
Practice Address - Fax:980-585-4415
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-09
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332BC3200X, 332BD1200X, 332BN1400X, 332BP3500X, 332BX2000X, 332B00000X
NC343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No332BD1200XSuppliersDurable Medical Equipment & Medical SuppliesDialysis Equipment & Supplies
No332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)