Provider Demographics
NPI:1619551926
Name:WELLS, DAWN HAYLA
Entity Type:Individual
Prefix:
First Name:DAWN
Middle Name:HAYLA
Last Name:WELLS
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 1:721 FAWCETT AVE
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98402-5502
Mailing Address - Country:US
Mailing Address - Phone:253-593-2413
Mailing Address - Fax:253-627-4817
Practice Address - Street 1:2143 BEVERLY BLVD
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584-2803
Practice Address - Country:US
Practice Address - Phone:253-593-2413
Practice Address - Fax:253-627-4817
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-12
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALP61138117164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty