Provider Demographics
NPI:1518155712
Name:SLEDGE, WAVELY LEE (DO)
Entity Type:Individual
Prefix:
First Name:WAVELY
Middle Name:LEE
Last Name:SLEDGE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 BIENVILLE DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28311-9335
Mailing Address - Country:US
Mailing Address - Phone:910-488-0598
Mailing Address - Fax:910-488-0598
Practice Address - Street 1:160 BIENVILLE DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28311-9335
Practice Address - Country:US
Practice Address - Phone:910-488-0598
Practice Address - Fax:910-488-0598
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-12
Last Update Date:2007-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC826156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8801882Medicaid