Provider Demographics
NPI:1558679605
Name:CORREA, WANDA I (RPT)
Entity Type:Individual
Prefix:MRS
First Name:WANDA
Middle Name:I
Last Name:CORREA
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:SAN AGUSTIN
Mailing Address - Street 2:C 20 CALLE 4
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00959
Mailing Address - Country:US
Mailing Address - Phone:787-475-0579
Mailing Address - Fax:787-783-1325
Practice Address - Street 1:SAN AGUSTIN
Practice Address - Street 2:C 20 CALLE 4
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00959
Practice Address - Country:US
Practice Address - Phone:787-475-0579
Practice Address - Fax:787-783-1325
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-22
Last Update Date:2010-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR7102251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics