Provider Demographics
NPI:1659085322
Name:BIBB, WANDA M (MPA, CLC)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:M
Last Name:BIBB
Suffix:
Gender:F
Credentials:MPA, CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4322 PARKER LN
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36116-3349
Mailing Address - Country:US
Mailing Address - Phone:334-207-0327
Mailing Address - Fax:
Practice Address - Street 1:1430 I85 PKWY STE 242
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36106-3635
Practice Address - Country:US
Practice Address - Phone:334-207-0327
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-09
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach