Provider Demographics
NPI:1124290457
Name:ROLAND, WANDA
Entity type:Individual
Prefix:MS
First Name:WANDA
Middle Name:
Last Name:ROLAND
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 1:1900 OLEVIA ST APT 239
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-3485
Mailing Address - Country:US
Mailing Address - Phone:773-573-3265
Mailing Address - Fax:
Practice Address - Street 1:3599 UNIVERSITY BLVD S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-4252
Practice Address - Country:US
Practice Address - Phone:904-345-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-26
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ1-0002227225100000X
FLPT31633225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE003778P91Medicare PIN