Provider Demographics
NPI:1609449719
Name:SYLVESTER-BAGENT, WANDA GAIL
Entity Type:Individual
Prefix:MRS
First Name:WANDA
Middle Name:GAIL
Last Name:SYLVESTER-BAGENT
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:WANDA
Other - Middle Name:GAIL
Other - Last Name:SYLVESTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 155
Mailing Address - Street 2:
Mailing Address - City:PORT BARRE
Mailing Address - State:LA
Mailing Address - Zip Code:70577-0155
Mailing Address - Country:US
Mailing Address - Phone:504-236-0916
Mailing Address - Fax:
Practice Address - Street 1:128 DEMANADE BLVD STE 201
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-2567
Practice Address - Country:US
Practice Address - Phone:225-261-7143
Practice Address - Fax:225-250-1026
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-19
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
5042360916OtherPERSONAL