Provider Demographics
NPI:1669677522
Name:SMITH, WANDA D (COF,CMF)
Entity Type:Individual
Prefix:MRS
First Name:WANDA
Middle Name:D
Last Name:SMITH
Suffix:
Gender:F
Credentials:COF,CMF
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2302 WAYNE MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27534-1726
Mailing Address - Country:US
Mailing Address - Phone:919-735-6936
Mailing Address - Fax:919-735-3001
Practice Address - Street 1:2302 WAYNE MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27534-1726
Practice Address - Country:US
Practice Address - Phone:919-735-6936
Practice Address - Fax:919-735-3001
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7795203225000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7795203Medicaid