Provider Demographics
NPI:1104638626
Name:DILLARD, WYVETTE
Entity type:Individual
Prefix:
First Name:WYVETTE
Middle Name:
Last Name:DILLARD
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 1:1122 STEPHENS ST
Mailing Address - Street 2:
Mailing Address - City:MARTINSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24112-4100
Mailing Address - Country:US
Mailing Address - Phone:276-806-5791
Mailing Address - Fax:276-336-4930
Practice Address - Street 1:1122 STEPHENS ST
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24112-4100
Practice Address - Country:US
Practice Address - Phone:276-806-5791
Practice Address - Fax:276-336-4930
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-22
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA30015085250001171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator