Provider Demographics
NPI:1659816783
Name:HERCULES, WANDA
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:
Last Name:HERCULES
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 1:569 EASTERN PKWY
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11216-4405
Mailing Address - Country:US
Mailing Address - Phone:347-385-3351
Mailing Address - Fax:
Practice Address - Street 1:569 EASTERN PKWY
Practice Address - Street 2:3RD FLOOR
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11216-4405
Practice Address - Country:US
Practice Address - Phone:347-385-3351
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-28
Last Update Date:2016-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist