Provider Demographics
NPI:1497206189
Name:MAYBERRY, WANDA
Entity type:Individual
Prefix:
First Name:WANDA
Middle Name:
Last Name:MAYBERRY
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:PO BOX 82
Mailing Address - Street 2:
Mailing Address - City:KEYSTONE HEIGHTS
Mailing Address - State:FL
Mailing Address - Zip Code:32656-0082
Mailing Address - Country:US
Mailing Address - Phone:352-448-9843
Mailing Address - Fax:888-213-4424
Practice Address - Street 1:1445 S LAWRENCE BLVD
Practice Address - Street 2:
Practice Address - City:KEYSTONE HEIGHTS
Practice Address - State:FL
Practice Address - Zip Code:32656-9349
Practice Address - Country:US
Practice Address - Phone:352-448-9843
Practice Address - Fax:888-213-4424
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-18
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities