Provider Demographics
NPI:1790936995
Name:FLETCHER, WILBUR R II (LPN)
Entity Type:Individual
Prefix:
First Name:WILBUR
Middle Name:R
Last Name:FLETCHER
Suffix:II
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 464423
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30042-4423
Mailing Address - Country:US
Mailing Address - Phone:678-571-1839
Mailing Address - Fax:
Practice Address - Street 1:34 FOX ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14212-1106
Practice Address - Country:US
Practice Address - Phone:678-571-1839
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-06
Last Update Date:2010-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY293237164W00000X
GALPN078869164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse