Provider Demographics
NPI:1285115824
Name:WELLS, JAMES DUSTIN
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:DUSTIN
Last Name:WELLS
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 1:3425 BANNERMAN RD STE 105-108
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32312-7062
Mailing Address - Country:US
Mailing Address - Phone:850-567-0759
Mailing Address - Fax:
Practice Address - Street 1:2868 CONCORD RD
Practice Address - Street 2:
Practice Address - City:HAVANA
Practice Address - State:FL
Practice Address - Zip Code:32333-4010
Practice Address - Country:US
Practice Address - Phone:850-567-0759
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-22
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCBC1252005171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor