Provider Demographics
NPI:1609086511
Name:WADE, WILDA FAYE (PHD,RD, LDN)
Entity Type:Individual
Prefix:
First Name:WILDA
Middle Name:FAYE
Last Name:WADE
Suffix:
Gender:F
Credentials:PHD,RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2007 YANCEYVILLE ST # 91
Mailing Address - Street 2:SUITE 407
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27405-5000
Mailing Address - Country:US
Mailing Address - Phone:336-339-2748
Mailing Address - Fax:
Practice Address - Street 1:2007 YANCEYVILLE ST # 91
Practice Address - Street 2:SUITE 407
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27405-5000
Practice Address - Country:US
Practice Address - Phone:336-542-5545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL001066133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC14306OtherBLUE CROSS BLUE SHIELD