Provider Demographics
NPI:1619572153
Name:WIGGINS, TIERRA LATRICE (APRN)
Entity Type:Individual
Prefix:
First Name:TIERRA
Middle Name:LATRICE
Last Name:WIGGINS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3910 BRIDGE RD STE 101
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23435-1107
Mailing Address - Country:US
Mailing Address - Phone:757-942-2566
Mailing Address - Fax:
Practice Address - Street 1:3910 BRIDGE RD STE 101
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23435-1107
Practice Address - Country:US
Practice Address - Phone:757-942-2566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-02
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024180432363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner