Provider Demographics
NPI:1235395286
Name:GANNON, WENDY FARRELL (NP)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:FARRELL
Last Name:GANNON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 BERNADINE DRIVE
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23602-4499
Mailing Address - Country:US
Mailing Address - Phone:757-947-3838
Mailing Address - Fax:757-886-6751
Practice Address - Street 1:2 BERNARDINE DR
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23602-4404
Practice Address - Country:US
Practice Address - Phone:757-947-3838
Practice Address - Fax:757-886-6751
Is Sole Proprietor?:No
Enumeration Date:2008-07-30
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024166408363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health