Provider Demographics
NPI:1255879151
Name:BERNHARDT, WANDA (LMT)
Entity type:Individual
Prefix:
First Name:WANDA
Middle Name:
Last Name:BERNHARDT
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 ELLIOTT ST
Mailing Address - Street 2:
Mailing Address - City:BEATTY
Mailing Address - State:NV
Mailing Address - Zip Code:89003
Mailing Address - Country:US
Mailing Address - Phone:775-553-2757
Mailing Address - Fax:
Practice Address - Street 1:1650 W. ELLIOTT ST
Practice Address - Street 2:
Practice Address - City:BEATTY
Practice Address - State:NV
Practice Address - Zip Code:89003-0669
Practice Address - Country:US
Practice Address - Phone:775-553-2757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-10
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNVMT6898171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor