Basic Information
| Provider Information | |||||||||
| NPI: | 1093064685 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WOLVERTON-WADE | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | LISA | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | RN, CWCN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 210 KEY HONEY LANE | ||||||||
| Address2: | |||||||||
| City: | TAVERNIER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8603280013 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3000 41ST ST | ||||||||
| Address2: | |||||||||
| City: | MARATHON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3054347660 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2012 | ||||||||
| LastUpdateDate: | 08/29/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WA0400X | RN9333023 | FL | Y | Nursing Service Providers | Registered Nurse | Addiction (Substance Use Disorder) | 163WP0809X | RN9333023 | FL | N | Nursing Service Providers | Registered Nurse | Psych/Mental Health, Adult | 163WW0000X | RN9333023 | FL | N | Nursing Service Providers | Registered Nurse | Wound Care |
No ID Information.