Provider Demographics
NPI:1215064779
Name:WINGATE, STELLA (PT)
Entity type:Individual
Prefix:
First Name:STELLA
Middle Name:
Last Name:WINGATE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:STELLA
Other - Middle Name:
Other - Last Name:FERNANDEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:PO BOX 40
Mailing Address - Street 2:
Mailing Address - City:MOULTRIE
Mailing Address - State:GA
Mailing Address - Zip Code:31776-0040
Mailing Address - Country:US
Mailing Address - Phone:229-985-3420
Mailing Address - Fax:
Practice Address - Street 1:3131 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MOULTRIE
Practice Address - State:GA
Practice Address - Zip Code:31768-6925
Practice Address - Country:US
Practice Address - Phone:229-985-3420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT008525225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA718566724CMedicaid
GA718566724BMedicaid
GAPT008525OtherGA PT LICENSE