Provider Demographics
NPI:1356793863
Name:WADLEY, FREDIA STOVALL
Entity type:Individual
Prefix:DR
First Name:FREDIA
Middle Name:STOVALL
Last Name:WADLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 S HANSON ST
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:MD
Mailing Address - Zip Code:21601-2920
Mailing Address - Country:US
Mailing Address - Phone:410-819-5606
Mailing Address - Fax:410-819-4703
Practice Address - Street 1:100 S HANSON ST
Practice Address - Street 2:
Practice Address - City:EASTON
Practice Address - State:MD
Practice Address - Zip Code:21601-2920
Practice Address - Country:US
Practice Address - Phone:410-819-5606
Practice Address - Fax:410-819-4703
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-08
Last Update Date:2016-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0066574208000000X
251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDM87082OtherSTATE OF MARYLAND CDS NUMBER