Provider Demographics
NPI:1669846648
Name:WADE, DUSTIN (LPN, BSHA, CPHQ)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:
Last Name:WADE
Suffix:
Gender:M
Credentials:LPN, BSHA, CPHQ
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4612 BRIDGEWOOD RD
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112-2812
Mailing Address - Country:US
Mailing Address - Phone:804-714-6120
Mailing Address - Fax:804-454-0855
Practice Address - Street 1:4612 BRIDGEWOOD RD
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-2812
Practice Address - Country:US
Practice Address - Phone:804-714-6120
Practice Address - Fax:804-454-0855
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-13
Last Update Date:2015-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0002082700376G00000X, 164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No376G00000XNursing Service Related ProvidersNursing Home Administrator