Provider Demographics
NPI:1700180197
Name:VILLARD, WANDA R (CNP)
Entity Type:Individual
Prefix:MS
First Name:WANDA
Middle Name:R
Last Name:VILLARD
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:MISS
Other - First Name:WANDA
Other - Middle Name:R
Other - Last Name:WORRELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2000 S FM 51
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:TX
Mailing Address - Zip Code:76234-3702
Mailing Address - Country:US
Mailing Address - Phone:940-626-1297
Mailing Address - Fax:940-626-8607
Practice Address - Street 1:2000 S FM 51
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:TX
Practice Address - Zip Code:76234-3702
Practice Address - Country:US
Practice Address - Phone:940-626-2590
Practice Address - Fax:940-626-2591
Is Sole Proprietor?:No
Enumeration Date:2010-12-29
Last Update Date:2019-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX789812363L00000X
TXAP119747363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX284407805Medicaid
TX8102NTOtherBCBSTX
TX284407805Medicaid