Provider Demographics
NPI:1801396809
Name:NORRIS, DWAYNE MITCHUM
Entity Type:Individual
Prefix:MR
First Name:DWAYNE
Middle Name:MITCHUM
Last Name:NORRIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1720 CAROL STREAM DR
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75081-2100
Mailing Address - Country:US
Mailing Address - Phone:214-205-8309
Mailing Address - Fax:
Practice Address - Street 1:1720 CAROL STREAM DR
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75081-2100
Practice Address - Country:US
Practice Address - Phone:214-205-8309
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-15
Last Update Date:2018-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX164295164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse