Provider Demographics
NPI:1790494151
Name:WOMACK, CHENEE
Entity Type:Individual
Prefix:
First Name:CHENEE
Middle Name:
Last Name:WOMACK
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 1:1742 LIBERTY RD
Mailing Address - Street 2:
Mailing Address - City:WOODLYN
Mailing Address - State:PA
Mailing Address - Zip Code:19094-1433
Mailing Address - Country:US
Mailing Address - Phone:148-448-5002
Mailing Address - Fax:
Practice Address - Street 1:1742 LIBERTY RD
Practice Address - Street 2:
Practice Address - City:WOODLYN
Practice Address - State:PA
Practice Address - Zip Code:19094-1433
Practice Address - Country:US
Practice Address - Phone:148-448-5002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-15
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA64443601251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA104054719-0001Medicaid