Provider Demographics
NPI:1750012050
Name:JUSTICE, WANDA
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:
Last Name:JUSTICE
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 1:254 CASSIDY BLVD
Mailing Address - Street 2:
Mailing Address - City:PIKEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41501-1426
Mailing Address - Country:US
Mailing Address - Phone:606-432-0238
Mailing Address - Fax:606-432-7658
Practice Address - Street 1:254 CASSIDY BLVD
Practice Address - Street 2:
Practice Address - City:PIKEVILLE
Practice Address - State:KY
Practice Address - Zip Code:41501-1426
Practice Address - Country:US
Practice Address - Phone:606-432-0238
Practice Address - Fax:606-432-7658
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-19
Last Update Date:2022-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY109938156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician