Provider Demographics
NPI:1750994679
Name:CAPTAIN, WANDA L
Entity type:Individual
Prefix:MRS
First Name:WANDA
Middle Name:L
Last Name:CAPTAIN
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 1:117 SYCAMORE DR
Mailing Address - Street 2:
Mailing Address - City:PENN HILLS
Mailing Address - State:PA
Mailing Address - Zip Code:15235-1965
Mailing Address - Country:US
Mailing Address - Phone:412-378-3311
Mailing Address - Fax:
Practice Address - Street 1:117 SYCAMORE DR
Practice Address - Street 2:
Practice Address - City:PENN HILLS
Practice Address - State:PA
Practice Address - Zip Code:15235-1965
Practice Address - Country:US
Practice Address - Phone:412-378-3311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-29
Last Update Date:2020-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA45243601253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care