Provider Demographics
NPI:1679909287
Name:WAINWRIGHT, NICOLE MALIA ROSALINE (IDMT)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:MALIA ROSALINE
Last Name:WAINWRIGHT
Suffix:
Gender:F
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1103 SUNDANCE HUNT
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78245-3428
Mailing Address - Country:US
Mailing Address - Phone:808-286-9713
Mailing Address - Fax:
Practice Address - Street 1:1103 SUNDANCE HUNT
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78245-3428
Practice Address - Country:US
Practice Address - Phone:808-286-9713
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-16
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians