Provider Demographics
NPI:1548763550
Name:WILLIAMS BAUGH, WANDA LATRICE
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:LATRICE
Last Name:WILLIAMS BAUGH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 22584
Mailing Address - Street 2:
Mailing Address - City:ROBBINSDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55422-0584
Mailing Address - Country:US
Mailing Address - Phone:763-381-2078
Mailing Address - Fax:
Practice Address - Street 1:4810 HUMBOLDT AVE N
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55430-3743
Practice Address - Country:US
Practice Address - Phone:763-381-2078
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-15
Last Update Date:2018-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy