Provider Demographics
NPI:1407142821
Name:WADDELL, LENORA A
Entity Type:Individual
Prefix:MS
First Name:LENORA
Middle Name:A
Last Name:WADDELL
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 1:1490 COUNTY ROAD 220
Mailing Address - Street 2:T-1497
Mailing Address - City:FLEMING ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32003
Mailing Address - Country:US
Mailing Address - Phone:904-278-9438
Mailing Address - Fax:904-278-9438
Practice Address - Street 1:1490 COUNTY ROAD 220
Practice Address - Street 2:T-1497
Practice Address - City:FLEMING ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32003
Practice Address - Country:US
Practice Address - Phone:904-278-9438
Practice Address - Fax:904-278-9438
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-23
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS28701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist