Provider Demographics
NPI:1467723478
Name:MERCED, WANDA (PTA)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:
Last Name:MERCED
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12598 EMERALD LAKE DR
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32407-3297
Mailing Address - Country:US
Mailing Address - Phone:850-258-2329
Mailing Address - Fax:
Practice Address - Street 1:12598 EMERALD LAKE DR
Practice Address - Street 2:
Practice Address - City:PANAMA CITY BEACH
Practice Address - State:FL
Practice Address - Zip Code:32407-3297
Practice Address - Country:US
Practice Address - Phone:850-258-2329
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-23
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA2300172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker