Provider Demographics
NPI:1679958995
Name:KING, WANDA
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:
Last Name:KING
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 1:2539 MEDICAL DR
Mailing Address - Street 2:STE 107
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88310-8720
Mailing Address - Country:US
Mailing Address - Phone:575-446-5940
Mailing Address - Fax:575-446-5944
Practice Address - Street 1:105 W STONE DR
Practice Address - Street 2:STE 4C
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-3365
Practice Address - Country:US
Practice Address - Phone:423-578-1595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-28
Last Update Date:2020-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN20121363L00000X
NMCNP-58574363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner