Provider Demographics
NPI:1063100162
Name:SERMON, WANDA LYNN (LPN)
Entity type:Individual
Prefix:
First Name:WANDA
Middle Name:LYNN
Last Name:SERMON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1266 TEANECK RD APT 8
Mailing Address - Street 2:
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666-4947
Mailing Address - Country:US
Mailing Address - Phone:917-567-5989
Mailing Address - Fax:
Practice Address - Street 1:350 PREAKNESS AVE
Practice Address - Street 2:
Practice Address - City:PATERSON
Practice Address - State:NJ
Practice Address - Zip Code:07502-1757
Practice Address - Country:US
Practice Address - Phone:973-595-1075
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-26
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NP07315800164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse