Provider Demographics
NPI:1174335004
Name:TATUM, WANDA NICOLE
Entity type:Individual
Prefix:
First Name:WANDA
Middle Name:NICOLE
Last Name:TATUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:WANDA
Other - Middle Name:NICOLE
Other - Last Name:BARNES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:95 W MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:CORTLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60112-4230
Mailing Address - Country:US
Mailing Address - Phone:312-307-1651
Mailing Address - Fax:
Practice Address - Street 1:95 W MEADOW DR
Practice Address - Street 2:
Practice Address - City:CORTLAND
Practice Address - State:IL
Practice Address - Zip Code:60112-4230
Practice Address - Country:US
Practice Address - Phone:312-307-1651
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-27
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILT35091465782172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver