Provider Demographics
NPI:1730422858
Name:STATEN, WANDA (LPN)
Entity type:Individual
Prefix:MISS
First Name:WANDA
Middle Name:
Last Name:STATEN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3014 BRUNER AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10469-3224
Mailing Address - Country:US
Mailing Address - Phone:917-679-4883
Mailing Address - Fax:212-531-8763
Practice Address - Street 1:3420 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10031-7418
Practice Address - Country:US
Practice Address - Phone:212-781-5500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-27
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY198235164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse