Provider Demographics
NPI:1629423751
Name:WELDON, SANTRESA
Entity Type:Individual
Prefix:
First Name:SANTRESA
Middle Name:
Last Name:WELDON
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 1:105 RENOIR LN
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088-6321
Mailing Address - Country:US
Mailing Address - Phone:478-971-7807
Mailing Address - Fax:
Practice Address - Street 1:105 RENOIR LN
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-6321
Practice Address - Country:US
Practice Address - Phone:478-971-7807
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-26
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACO087817174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist