Provider Demographics
NPI:1851623680
Name:WAINWRIGHT, JERRY WAYNE (LPN)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:WAYNE
Last Name:WAINWRIGHT
Suffix:
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 1:18388 HARRY JONES RD N
Mailing Address - Street 2:
Mailing Address - City:SUMMERDALE
Mailing Address - State:AL
Mailing Address - Zip Code:36580-3485
Mailing Address - Country:US
Mailing Address - Phone:251-367-4673
Mailing Address - Fax:
Practice Address - Street 1:18388 HARRY JONES RD N
Practice Address - Street 2:
Practice Address - City:SUMMERDALE
Practice Address - State:AL
Practice Address - Zip Code:36580-3485
Practice Address - Country:US
Practice Address - Phone:251-367-4673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-04
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2-037466164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL164WOOOOOXMedicare PIN