Provider Demographics
NPI:1639171234
Name:DEDEAUX, WANDA JANE (FNP)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:JANE
Last Name:DEDEAUX
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4622 EMERSON ST
Mailing Address - Street 2:
Mailing Address - City:PASCAGOULA
Mailing Address - State:MS
Mailing Address - Zip Code:39581-4713
Mailing Address - Country:US
Mailing Address - Phone:228-623-5632
Mailing Address - Fax:228-712-2374
Practice Address - Street 1:1820 OLD MOBILE AVE
Practice Address - Street 2:
Practice Address - City:PASCAGOULA
Practice Address - State:MS
Practice Address - Zip Code:39567-4412
Practice Address - Country:US
Practice Address - Phone:228-696-0230
Practice Address - Fax:228-712-2374
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR744414363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00120206Medicaid
MS500000408Medicare ID - Type Unspecified
MSS69488Medicare UPIN