Provider Demographics
NPI:1053546556
Name:ELMORE, WONDA FAY
Entity type:Individual
Prefix:
First Name:WONDA
Middle Name:FAY
Last Name:ELMORE
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 1:255 N MIAMI ST
Mailing Address - Street 2:
Mailing Address - City:WABASH
Mailing Address - State:IN
Mailing Address - Zip Code:46992-2705
Mailing Address - Country:US
Mailing Address - Phone:574-385-3145
Mailing Address - Fax:260-563-1902
Practice Address - Street 1:255 N MIAMI ST
Practice Address - Street 2:
Practice Address - City:WABASH
Practice Address - State:IN
Practice Address - Zip Code:46992-2705
Practice Address - Country:US
Practice Address - Phone:574-385-3145
Practice Address - Fax:260-563-1902
Is Sole Proprietor?:No
Enumeration Date:2009-05-27
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71002916B363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300002655Medicaid
IN000001090820OtherANTHEM
INP00961639OtherRAIL ROAD MEDICARE
IN351513328OtherCRAIG R JOHNSTON
INP00961639OtherRAIL ROAD MEDICARE