Provider Demographics
NPI:1558945808
Name:WAYNES, EUDORA JASMINE
Entity Type:Individual
Prefix:MS
First Name:EUDORA
Middle Name:JASMINE
Last Name:WAYNES
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 1:41 IRVING ST
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11580-1634
Mailing Address - Country:US
Mailing Address - Phone:646-431-9446
Mailing Address - Fax:516-285-0518
Practice Address - Street 1:41 IRVING ST
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11580-1634
Practice Address - Country:US
Practice Address - Phone:646-431-9446
Practice Address - Fax:516-285-0518
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-11
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency