Provider Demographics
NPI:1033450747
Name:WOULLARD, DWANA SHANEE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:DWANA
Middle Name:SHANEE
Last Name:WOULLARD
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4675 OLD SALEM RD
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:TERRITORY
Mailing Address - Zip Code:45322
Mailing Address - Country:UM
Mailing Address - Phone:937-572-7131
Mailing Address - Fax:
Practice Address - Street 1:4675 OLD SALEM RD
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:OH
Practice Address - Zip Code:45322-2509
Practice Address - Country:US
Practice Address - Phone:937-572-7131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-05
Last Update Date:2013-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH116003164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse