Provider Demographics
NPI:1689413460
Name:WELLS, DESTINEY JORDAN
Entity type:Individual
Prefix:
First Name:DESTINEY
Middle Name:JORDAN
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 1:1605 GRAND CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:WV
Mailing Address - Zip Code:26105-1081
Mailing Address - Country:US
Mailing Address - Phone:304-295-7290
Mailing Address - Fax:
Practice Address - Street 1:1605 GRAND CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:WV
Practice Address - Zip Code:26105-1081
Practice Address - Country:US
Practice Address - Phone:304-295-7290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-22
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty