Provider Demographics
NPI:1902077415
Name:WADE, MARY CELESTE (RT)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:CELESTE
Last Name:WADE
Suffix:
Gender:F
Credentials:RT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1029 TRAVELERS TRL NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-2870
Mailing Address - Country:US
Mailing Address - Phone:770-428-1026
Mailing Address - Fax:
Practice Address - Street 1:1029 TRAVELERS TRL NW
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-2870
Practice Address - Country:US
Practice Address - Phone:770-428-1026
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-12
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01200053002471C3402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471C3402XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistRadiography