Basic Information
| Provider Information | |||||||||
| NPI: | 1942503834 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HILLIARD | ||||||||
| FirstName: | WANDA | ||||||||
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| Credential: | PMHNP-BC,APN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9813 MEMORIAL BLVD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | HUMBLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773384274 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2819133550 | ||||||||
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| Practice Location | |||||||||
| Address1: | 30 TECHNOLOGY DR | ||||||||
| Address2: | |||||||||
| City: | ROCKY MOUNT | ||||||||
| State: | VA | ||||||||
| PostalCode: | 241513008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5404830582 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2010 | ||||||||
| LastUpdateDate: | 06/04/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 703524 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363LP0808X | AP119602 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363LP0808X | 0024178774 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.