Provider Demographics
NPI:1629306139
Name:WIGFALL, MARSHALL ROMONA (DNP, FNP, PMH-NP/CNS)
Entity Type:Individual
Prefix:MRS
First Name:MARSHALL
Middle Name:ROMONA
Last Name:WIGFALL
Suffix:
Gender:F
Credentials:DNP, FNP, PMH-NP/CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1556
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23113-1556
Mailing Address - Country:US
Mailing Address - Phone:804-594-6837
Mailing Address - Fax:804-621-2248
Practice Address - Street 1:1700 HUGUENOT RD STE E
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23113-2397
Practice Address - Country:US
Practice Address - Phone:804-594-6837
Practice Address - Fax:804-621-2248
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-20
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001190712163W00000X
VA0015000882364SP0808X
VA0024168559363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
No364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1629306139Medicaid
VA1336293000Medicaid