Provider Demographics
NPI:1093165607
Name:GARRETT, DYANDRA
Entity Type:Individual
Prefix:
First Name:DYANDRA
Middle Name:
Last Name:GARRETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DYANDRA
Other - Middle Name:
Other - Last Name:HENDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4144 SPRINGBURN DR
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43615-6549
Mailing Address - Country:US
Mailing Address - Phone:419-356-4123
Mailing Address - Fax:
Practice Address - Street 1:6605 W CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43617-1000
Practice Address - Country:US
Practice Address - Phone:419-841-7701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-14
Last Update Date:2016-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN115357164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse