Provider Demographics
NPI:1699835967
Name:WANDERER, KATHY L (LAC)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:L
Last Name:WANDERER
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 RIDGE RD # A
Mailing Address - Street 2:
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75087-4217
Mailing Address - Country:US
Mailing Address - Phone:972-772-3327
Mailing Address - Fax:972-772-3327
Practice Address - Street 1:1105 RIDGE RD # A
Practice Address - Street 2:
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75087-4217
Practice Address - Country:US
Practice Address - Phone:972-772-3327
Practice Address - Fax:972-772-3327
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAC00565171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist