Provider Demographics
NPI:1114516481
Name:WENTWORTH, ELITHA DEIDRA
Entity Type:Individual
Prefix:
First Name:ELITHA
Middle Name:DEIDRA
Last Name:WENTWORTH
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 1:5800 W SLAUGHTER LN
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78749-6507
Mailing Address - Country:US
Mailing Address - Phone:512-301-9772
Mailing Address - Fax:866-369-0549
Practice Address - Street 1:5800 W SLAUGHTER LN
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78749-6507
Practice Address - Country:US
Practice Address - Phone:512-301-9772
Practice Address - Fax:866-369-0549
Is Sole Proprietor?:No
Enumeration Date:2021-01-12
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX141287183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician