Provider Demographics
NPI:1053777573
Name:WADDELL, STEPHEN
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:WADDELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8160 N HENPECK RD
Mailing Address - Street 2:
Mailing Address - City:QUINTON
Mailing Address - State:VA
Mailing Address - Zip Code:23141-2313
Mailing Address - Country:US
Mailing Address - Phone:804-304-6241
Mailing Address - Fax:
Practice Address - Street 1:1307 JAMESTOWN RD
Practice Address - Street 2:STE. 103
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23185-3381
Practice Address - Country:US
Practice Address - Phone:757-229-4161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-13
Last Update Date:2016-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019008434174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator