Provider Demographics
NPI:1003207630
Name:WESLEY, LENORA DIANN
Entity Type:Individual
Prefix:
First Name:LENORA
Middle Name:DIANN
Last Name:WESLEY
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 1:7840 HERRINGTON DRIVE
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32534
Mailing Address - Country:US
Mailing Address - Phone:850-477-0914
Mailing Address - Fax:
Practice Address - Street 1:7840 HERRINGTON DRIVE
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32534
Practice Address - Country:US
Practice Address - Phone:850-477-0914
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-18
Last Update Date:2015-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6905237OtherAHCA LICENSE
FL141559000Medicaid