Provider Demographics
NPI:1669682944
Name:DEAN, WILLIE RUTH (LVN)
Entity Type:Individual
Prefix:
First Name:WILLIE
Middle Name:RUTH
Last Name:DEAN
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:MRS
Other - First Name:WILLIE
Other - Middle Name:RUTH
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LVN
Mailing Address - Street 1:5288 BARBADOS CIR
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95210-6605
Mailing Address - Country:US
Mailing Address - Phone:209-688-7720
Mailing Address - Fax:
Practice Address - Street 1:1012 RAUBE CT
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95351-2417
Practice Address - Country:US
Practice Address - Phone:209-544-9377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN128313164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEPSO16000Medicaid