Provider Demographics
NPI:1457035800
Name:WELLS, DESTINY
Entity Type:Individual
Prefix:
First Name:DESTINY
Middle Name:
Last Name:WELLS
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:DAMON
Other - Middle Name:JASER
Other - Last Name:WELLS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:124 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95678-2232
Mailing Address - Country:US
Mailing Address - Phone:916-547-3737
Mailing Address - Fax:
Practice Address - Street 1:124 MAIN ST
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95678-2232
Practice Address - Country:US
Practice Address - Phone:916-547-3737
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-14
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator