Provider Demographics
NPI:1780032359
Name:WELLS, ANNIE
Entity Type:Individual
Prefix:MRS
First Name:ANNIE
Middle Name:
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 1:3113 MOORE STATION RD
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71108-5043
Mailing Address - Country:US
Mailing Address - Phone:318-423-4561
Mailing Address - Fax:318-848-7713
Practice Address - Street 1:3113 MOORE STATION RD
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71108-5043
Practice Address - Country:US
Practice Address - Phone:318-423-4561
Practice Address - Fax:318-848-7713
Is Sole Proprietor?:No
Enumeration Date:2016-05-24
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA002803974171WV0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WV0202XOther Service ProvidersContractorVehicle Modifications
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA811916782Medicaid