Provider Demographics
NPI:1316725823
Name:WADE, HEATHER ANN
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:ANN
Last Name:WADE
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 1:1149 NIMMO PKWY
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23456-7730
Mailing Address - Country:US
Mailing Address - Phone:757-563-2636
Mailing Address - Fax:757-563-2438
Practice Address - Street 1:1149 NIMMO PKWY
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23456-7730
Practice Address - Country:US
Practice Address - Phone:757-563-2636
Practice Address - Fax:757-563-2438
Is Sole Proprietor?:No
Enumeration Date:2023-09-18
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1101003274156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician