Provider Demographics
NPI:1972806412
Name:WOMACK, DELORES TRESA (LPN AND LSW)
Entity Type:Individual
Prefix:
First Name:DELORES
Middle Name:TRESA
Last Name:WOMACK
Suffix:
Gender:F
Credentials:LPN AND LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1719 ROBERTS LN NE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44483-3621
Mailing Address - Country:US
Mailing Address - Phone:330-559-2596
Mailing Address - Fax:
Practice Address - Street 1:1719 ROBERTS LN NE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44483
Practice Address - Country:US
Practice Address - Phone:330-559-2596
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-06
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN119097164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0279702Medicaid