Provider Demographics
NPI:1548591324
Name:CHAMPION, WANDA BATES (CFTS, CFM)
Entity Type:Individual
Prefix:MRS
First Name:WANDA
Middle Name:BATES
Last Name:CHAMPION
Suffix:
Gender:F
Credentials:CFTS, CFM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:139 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FOREST CITY
Mailing Address - State:NC
Mailing Address - Zip Code:28043-3125
Mailing Address - Country:US
Mailing Address - Phone:828-245-4591
Mailing Address - Fax:828-245-1793
Practice Address - Street 1:139 E MAIN ST
Practice Address - Street 2:
Practice Address - City:FOREST CITY
Practice Address - State:NC
Practice Address - Zip Code:28043-3125
Practice Address - Country:US
Practice Address - Phone:828-245-4591
Practice Address - Fax:828-245-1793
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-19
Last Update Date:2012-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCCFTS0820225000000X
NCCFM02654224900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter
No224900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMastectomy Fitter