Provider Demographics
NPI:1568636561
Name:CHISHOLM, WANDA
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:
Last Name:CHISHOLM
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 311365
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33680
Mailing Address - Country:US
Mailing Address - Phone:813-231-3146
Mailing Address - Fax:813-231-3146
Practice Address - Street 1:1304 E OSBORNE AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33603
Practice Address - Country:US
Practice Address - Phone:813-231-3146
Practice Address - Fax:813-231-3146
Is Sole Proprietor?:No
Enumeration Date:2008-04-22
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL691790998Medicaid
FL691790996Medicaid