Provider Demographics
NPI:1457477481
Name:WADE, VIRGIE C (FNP)
Entity Type:Individual
Prefix:MRS
First Name:VIRGIE
Middle Name:C
Last Name:WADE
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 1:300 COUNTY ROAD 275
Mailing Address - Street 2:
Mailing Address - City:VOSSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39366-9475
Mailing Address - Country:US
Mailing Address - Phone:601-776-2052
Mailing Address - Fax:
Practice Address - Street 1:130 NORTH HIGH ST
Practice Address - Street 2:
Practice Address - City:SHUBUTA
Practice Address - State:MS
Practice Address - Zip Code:39360
Practice Address - Country:US
Practice Address - Phone:601-687-1391
Practice Address - Fax:601-687-0051
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR119030363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS011312Medicaid
MS011312Medicaid