Provider Demographics
NPI:1336254648
Name:STREET, WANDA LISA (APRN-BC)
Entity Type:Individual
Prefix:MRS
First Name:WANDA
Middle Name:LISA
Last Name:STREET
Suffix:
Gender:F
Credentials:APRN-BC
Other - Prefix:
Other - First Name:WANDA
Other - Middle Name:LISA
Other - Last Name:MONROIG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1654 OSSAHATCHIE CREEK RD
Mailing Address - Street 2:
Mailing Address - City:ELLERSLIE
Mailing Address - State:GA
Mailing Address - Zip Code:31807-5342
Mailing Address - Country:US
Mailing Address - Phone:706-582-3575
Mailing Address - Fax:
Practice Address - Street 1:6600 VAN AALST BLVD
Practice Address - Street 2:
Practice Address - City:FORT BENNING
Practice Address - State:GA
Practice Address - Zip Code:31905-2102
Practice Address - Country:US
Practice Address - Phone:706-544-8688
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN140175163WP0809X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAQ49569Medicare UPIN
89BBBKKMedicare ID - Type Unspecified