Provider Demographics
NPI:1376767566
Name:ISOM, WENDY L (LMBT)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:L
Last Name:ISOM
Suffix:
Gender:F
Credentials:LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5720 WOODRIDGE CT
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28027-8097
Mailing Address - Country:US
Mailing Address - Phone:704-425-8046
Mailing Address - Fax:704-784-8733
Practice Address - Street 1:300 COPPERFIELD BLVD NE STE 205-D
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2428
Practice Address - Country:US
Practice Address - Phone:704-425-8046
Practice Address - Fax:704-784-8733
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3416174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist