Provider Demographics
NPI:1366101784
Name:WADDLE, SHAUNDA LYN (CSFA)
Entity type:Individual
Prefix:MRS
First Name:SHAUNDA
Middle Name:LYN
Last Name:WADDLE
Suffix:
Gender:F
Credentials:CSFA
Other - Prefix:MISS
Other - First Name:SHAUNDA
Other - Middle Name:LYN
Other - Last Name:LAMPHERE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CSFA
Mailing Address - Street 1:5001 OPAL DR
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-5693
Mailing Address - Country:US
Mailing Address - Phone:307-214-6537
Mailing Address - Fax:
Practice Address - Street 1:5001 OPAL DR
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-5693
Practice Address - Country:US
Practice Address - Phone:307-214-6537
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-13
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY206758246ZC0007X
363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant