Provider Demographics
NPI:1124151014
Name:PROMMART, WANNA (PSYD)
Entity type:Individual
Prefix:DR
First Name:WANNA
Middle Name:
Last Name:PROMMART
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:491 NAYLOR PL
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22304-2227
Mailing Address - Country:US
Mailing Address - Phone:571-722-8872
Mailing Address - Fax:
Practice Address - Street 1:205 S WHITING ST
Practice Address - Street 2:SUITE 601
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22304-2227
Practice Address - Country:US
Practice Address - Phone:571-722-8872
Practice Address - Fax:703-212-8407
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810003512103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
11551672OtherACQH
199902OtherANTHEM BLUE CROSS BLUE SH
3403124OtherCIGNA
361274OtherMHN
027984OtherVMC BEHAVIOR HEALTH SERVI
3769OtherCAREFIRST BLUE CROSS BLUE
3769OtherCAREFIRST BLUE CROSS BLUE