1629217096 NPI number — MS. SHEMENA MONIQUE WIGGINS PT

Table of content: MS. SHEMENA MONIQUE WIGGINS PT (NPI 1629217096)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629217096 NPI number — MS. SHEMENA MONIQUE WIGGINS PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WIGGINS
Provider First Name:
SHEMENA
Provider Middle Name:
MONIQUE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1629217096
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/09/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3823 LAWNDALE DR.
Provider Second Line Business Mailing Address:
LOYALTON OF GREENSBORO
Provider Business Mailing Address City Name:
GREENSBORO
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27284
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-286-7076
Provider Business Mailing Address Fax Number:
336-286-7077

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3823 LAWNDALE DR.
Provider Second Line Business Practice Location Address:
LOYALTON OF GREENSBORO
Provider Business Practice Location Address City Name:
GREENSBORO
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27455
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-286-7076
Provider Business Practice Location Address Fax Number:
336-286-7076
Provider Enumeration Date:
02/09/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  11623 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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