Provider Demographics
NPI:1093960601
Name:SMITH-HERNDON, WANDA
Entity type:Individual
Prefix:
First Name:WANDA
Middle Name:
Last Name:SMITH-HERNDON
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 1:464 NORTH END OAKLEY DR.
Mailing Address - Street 2:APT. G108
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31906
Mailing Address - Country:US
Mailing Address - Phone:706-464-4232
Mailing Address - Fax:
Practice Address - Street 1:2100 COMER AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-8725
Practice Address - Country:US
Practice Address - Phone:706-596-5883
Practice Address - Fax:706-596-5889
Is Sole Proprietor?:No
Enumeration Date:2008-11-24
Last Update Date:2008-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA042791164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse