Provider Demographics
NPI:1457133597
Name:GREGG, WANDA (HOME HEALTH)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:
Last Name:GREGG
Suffix:
Gender:F
Credentials:HOME HEALTH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5609 12TH AVE S
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33707-3406
Mailing Address - Country:US
Mailing Address - Phone:727-768-6459
Mailing Address - Fax:
Practice Address - Street 1:5609 12TH AVE S
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:FL
Practice Address - Zip Code:33707-3406
Practice Address - Country:US
Practice Address - Phone:727-768-6459
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-13
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCNA160714376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL933538904OtherHEALTHCARE