Provider Demographics
NPI:1457460669
Name:MCDANIEL, WANDA (FNP-C)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:
Last Name:MCDANIEL
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 KELLY RD
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-6012
Mailing Address - Country:US
Mailing Address - Phone:770-957-1887
Mailing Address - Fax:770-957-6864
Practice Address - Street 1:50 KELLY RD
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-6012
Practice Address - Country:US
Practice Address - Phone:770-957-1887
Practice Address - Fax:770-957-6864
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN038289NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1153620002OtherPEACHSTATE
GA10033124OtherAMERIGROUP
GA319962OtherWELLCARE
GA000821356AMedicaid
GA319962OtherWELLCARE
GAS52767Medicare UPIN