Provider Demographics
NPI:1316753593
Name:WILBORN, DEIDRA M (CHW)
Entity type:Individual
Prefix:
First Name:DEIDRA
Middle Name:M
Last Name:WILBORN
Suffix:
Gender:F
Credentials:CHW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 65495
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79464-5495
Mailing Address - Country:US
Mailing Address - Phone:806-438-9891
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 65495
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79464-5495
Practice Address - Country:US
Practice Address - Phone:806-438-9891
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-03
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13418172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker