Provider Demographics
NPI:1659060382
Name:EVERETT, WANDER
Entity Type:Individual
Prefix:
First Name:WANDER
Middle Name:
Last Name:EVERETT
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 1:1722 FOXFIRE CIR
Mailing Address - Street 2:
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23238-4212
Mailing Address - Country:US
Mailing Address - Phone:804-839-8830
Mailing Address - Fax:
Practice Address - Street 1:1722 FOXFIRE CIR
Practice Address - Street 2:
Practice Address - City:HENRICO
Practice Address - State:VA
Practice Address - Zip Code:23238-4212
Practice Address - Country:US
Practice Address - Phone:804-839-8830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-08
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001251326363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care