Provider Demographics
NPI:1821591538
Name:WAYNE, DEVON NICHOLE (MPH, ATC, CHES, CWHC)
Entity Type:Individual
Prefix:MISS
First Name:DEVON
Middle Name:NICHOLE
Last Name:WAYNE
Suffix:
Gender:F
Credentials:MPH, ATC, CHES, CWHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 W SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92805-4414
Mailing Address - Country:US
Mailing Address - Phone:714-624-6601
Mailing Address - Fax:
Practice Address - Street 1:2212 E 4TH ST STE 301
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-3873
Practice Address - Country:US
Practice Address - Phone:714-571-7727
Practice Address - Fax:714-744-0136
Is Sole Proprietor?:No
Enumeration Date:2018-03-09
Last Update Date:2018-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA206022255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer