Provider Demographics
NPI:1245903350
Name:WELLS, CYDNEI OCTAVIA (LAT)
Entity type:Individual
Prefix:
First Name:CYDNEI
Middle Name:OCTAVIA
Last Name:WELLS
Suffix:
Gender:F
Credentials:LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 OLD BRANDON RD
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76670-1182
Mailing Address - Country:US
Mailing Address - Phone:903-922-1362
Mailing Address - Fax:
Practice Address - Street 1:123 N COLLEGE ST
Practice Address - Street 2:
Practice Address - City:ITASCA
Practice Address - State:TX
Practice Address - Zip Code:76055-2307
Practice Address - Country:US
Practice Address - Phone:254-687-2922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-26
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT90102255A2300X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer