Provider Demographics
NPI:1942797386
Name:GROSS, WANDA RIGINA (NURSE ASSISTANT)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:RIGINA
Last Name:GROSS
Suffix:
Gender:F
Credentials:NURSE ASSISTANT
Other - Prefix:
Other - First Name:WANDA
Other - Middle Name:RIGINA
Other - Last Name:GROSS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:AGAPE SENIOR CARE LL
Mailing Address - Street 1:1423 DUNWOODY AVE
Mailing Address - Street 2:
Mailing Address - City:OXON HILL
Mailing Address - State:MD
Mailing Address - Zip Code:20745-2340
Mailing Address - Country:US
Mailing Address - Phone:240-838-6935
Mailing Address - Fax:240-719-3953
Practice Address - Street 1:1423 DUNWOODY AVE
Practice Address - Street 2:
Practice Address - City:OXON HILL
Practice Address - State:MD
Practice Address - Zip Code:20745-2340
Practice Address - Country:US
Practice Address - Phone:240-838-6935
Practice Address - Fax:240-719-3953
Is Sole Proprietor?:No
Enumeration Date:2018-04-20
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR4805376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1487192910Medicaid
MDR4805OtherRESIDENTIAL SERVICES LICENSE
MD1487192910OtherIRS EIN