Provider Demographics
NPI:1649346271
Name:LIDDELL, WANDA B (ARNP)
Entity type:Individual
Prefix:MRS
First Name:WANDA
Middle Name:B
Last Name:LIDDELL
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 NE HWY 351
Mailing Address - Street 2:
Mailing Address - City:CROSS CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32628
Mailing Address - Country:US
Mailing Address - Phone:352-498-3372
Mailing Address - Fax:352-498-7119
Practice Address - Street 1:306 NE HWY 351
Practice Address - Street 2:
Practice Address - City:CROSS CITY
Practice Address - State:FL
Practice Address - Zip Code:32628
Practice Address - Country:US
Practice Address - Phone:352-498-3372
Practice Address - Fax:352-498-7119
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1569472207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY7250OtherBCBS
FLY7250OtherBCBS
FLY7250YMedicare ID - Type Unspecified