Provider Demographics
NPI:1154774826
Name:WELLS, DESTINEE A
Entity type:Individual
Prefix:
First Name:DESTINEE
Middle Name:A
Last Name:WELLS
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 1:4334 RIDGEWAY CIR
Mailing Address - Street 2:APT E
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49006-6240
Mailing Address - Country:US
Mailing Address - Phone:847-987-4467
Mailing Address - Fax:
Practice Address - Street 1:4334 RIDGEWAY CIR
Practice Address - Street 2:APT E
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49006-6240
Practice Address - Country:US
Practice Address - Phone:847-987-4467
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-19
Last Update Date:2016-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner