Provider Demographics
NPI:1982127247
Name:WIGGINS, KATY MARIE JACKSON (REGISTERED NURSE)
Entity type:Individual
Prefix:
First Name:KATY
Middle Name:MARIE JACKSON
Last Name:WIGGINS
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9309 POLE RUN RD
Mailing Address - Street 2:
Mailing Address - City:DISPUTANTA
Mailing Address - State:VA
Mailing Address - Zip Code:23842-5524
Mailing Address - Country:US
Mailing Address - Phone:804-712-0855
Mailing Address - Fax:
Practice Address - Street 1:12801 IRON BRIDGE RD
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:VA
Practice Address - Zip Code:23831-1669
Practice Address - Country:US
Practice Address - Phone:804-748-9071
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-19
Last Update Date:2017-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001222327163WC1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1600XNursing Service ProvidersRegistered NurseContinuing Education/Staff Development