Basic Information
| Provider Information | |||||||||
| NPI: | 1477861623 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RADFORD | ||||||||
| FirstName: | WANDA | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1717 N E ST | ||||||||
| Address2: | STE 331 | ||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325016335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504846500 | ||||||||
| FaxNumber: | 8508571747 | ||||||||
| Practice Location | |||||||||
| Address1: | 1717 N E ST | ||||||||
| Address2: | STE 331 | ||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325016335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504846500 | ||||||||
| FaxNumber: | 8508571747 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2010 | ||||||||
| LastUpdateDate: | 02/04/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | ARNP 2609562 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.