Provider Demographics
NPI:1902370273
Name:DALLAS, WANDRIA COLEMAN (APRN)
Entity Type:Individual
Prefix:MRS
First Name:WANDRIA
Middle Name:COLEMAN
Last Name:DALLAS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3902 ELMER LN
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71109-1934
Mailing Address - Country:US
Mailing Address - Phone:318-560-2295
Mailing Address - Fax:
Practice Address - Street 1:1541 KINGS HWY
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4228
Practice Address - Country:US
Practice Address - Phone:318-626-1855
Practice Address - Fax:318-698-8182
Is Sole Proprietor?:No
Enumeration Date:2019-01-19
Last Update Date:2019-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP10195364SG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SG0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGerontology