Provider Demographics
NPI:1548756125
Name:WOMACK, DRAYDESE C
Entity Type:Individual
Prefix:
First Name:DRAYDESE
Middle Name:C
Last Name:WOMACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DRAYDESE
Other - Middle Name:C
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6802 TALL OAK DR
Mailing Address - Street 2:
Mailing Address - City:TEMPLE HILLS
Mailing Address - State:MD
Mailing Address - Zip Code:20748-3914
Mailing Address - Country:US
Mailing Address - Phone:301-318-1559
Mailing Address - Fax:
Practice Address - Street 1:6802 TALL OAK DR
Practice Address - Street 2:
Practice Address - City:TEMPLE HILLS
Practice Address - State:MD
Practice Address - Zip Code:20748-3914
Practice Address - Country:US
Practice Address - Phone:301-318-1559
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-06
Last Update Date:2018-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA510078880021Medicaid