Provider Demographics
NPI:1689107351
Name:WIGGINS, DONISE
Entity Type:Individual
Prefix:
First Name:DONISE
Middle Name:
Last Name:WIGGINS
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 1:2234 S ST SE APT 1
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20020-4503
Mailing Address - Country:US
Mailing Address - Phone:202-713-4059
Mailing Address - Fax:
Practice Address - Street 1:2234 S ST SE APT 1
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20020-4503
Practice Address - Country:US
Practice Address - Phone:202-713-4059
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-09
Last Update Date:2017-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC28893771710I1003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC70083498Medicaid