Provider Demographics
NPI:1619396090
Name:COCKRAN, WANDA
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:
Last Name:COCKRAN
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 1:6617 YOSEMITE DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76112-5236
Mailing Address - Country:US
Mailing Address - Phone:469-765-6234
Mailing Address - Fax:
Practice Address - Street 1:6617 YOSEMITE DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76112-5236
Practice Address - Country:US
Practice Address - Phone:469-765-6234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-14
Last Update Date:2014-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator