Provider Demographics
NPI:1619599735
Name:WOMBLES, BRIAN GLEN
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:GLEN
Last Name:WOMBLES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5016 WATERCREST RD APT 9104
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76549-6380
Mailing Address - Country:US
Mailing Address - Phone:270-707-6146
Mailing Address - Fax:
Practice Address - Street 1:5016 WATERCREST RD APT 9104
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76549-6380
Practice Address - Country:US
Practice Address - Phone:270-707-6146
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-12
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2035078164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse