Provider Demographics
NPI:1205248085
Name:DAVIS, WYNNETTE
Entity type:Individual
Prefix:
First Name:WYNNETTE
Middle Name:
Last Name:DAVIS
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 1:11901 BROOKVALLEY CIR APT A
Mailing Address - Street 2:
Mailing Address - City:BALCH SPRINGS
Mailing Address - State:TX
Mailing Address - Zip Code:75180-2864
Mailing Address - Country:US
Mailing Address - Phone:214-881-2262
Mailing Address - Fax:
Practice Address - Street 1:11901 BROOKVALLEY CIR APT A
Practice Address - Street 2:
Practice Address - City:BALCH SPRINGS
Practice Address - State:TX
Practice Address - Zip Code:75180-2864
Practice Address - Country:US
Practice Address - Phone:214-881-2262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-28
Last Update Date:2014-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8498618374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8498618OtherCNA CERTIFICATION