Provider Demographics
NPI:1417587890
Name:WADE, ABIGAIL B (DC)
Entity Type:Individual
Prefix:
First Name:ABIGAIL
Middle Name:B
Last Name:WADE
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1332 W ARCH HAVEN AVE STE C
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-2078
Mailing Address - Country:US
Mailing Address - Phone:812-333-7447
Mailing Address - Fax:812-333-7442
Practice Address - Street 1:1332 W ARCH HAVEN AVE STE C
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-2078
Practice Address - Country:US
Practice Address - Phone:812-333-7447
Practice Address - Fax:812-333-7442
Is Sole Proprietor?:No
Enumeration Date:2020-01-24
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08003119A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300042529Medicaid