Provider Demographics
NPI:1407997190
Name:WAZENEGGER, WANDA E (FNP)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:E
Last Name:WAZENEGGER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 COURT SQ
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27330-5657
Mailing Address - Country:US
Mailing Address - Phone:919-718-5705
Mailing Address - Fax:919-777-7248
Practice Address - Street 1:310 COURT SQ
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:NC
Practice Address - Zip Code:27330-5657
Practice Address - Country:US
Practice Address - Phone:919-718-5705
Practice Address - Fax:919-777-7248
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2011-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200765363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCS25227Medicare UPIN