Provider Demographics
NPI:1568883379
Name:PURNELL, WANDA
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:
Last Name:PURNELL
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 1:7621 PITCHER PT APT 203
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN
Mailing Address - State:CO
Mailing Address - Zip Code:80817-4816
Mailing Address - Country:US
Mailing Address - Phone:719-526-6009
Mailing Address - Fax:
Practice Address - Street 1:7621 PITCHER PT APT 203
Practice Address - Street 2:
Practice Address - City:FOUNTAIN
Practice Address - State:CO
Practice Address - Zip Code:80817-4816
Practice Address - Country:US
Practice Address - Phone:719-526-6009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-20
Last Update Date:2013-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0002059367164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse