Provider Demographics
NPI:1770157364
Name:HINES, WANDA
Entity type:Individual
Prefix:
First Name:WANDA
Middle Name:
Last Name:HINES
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 1:343 W PARKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45405-3222
Mailing Address - Country:US
Mailing Address - Phone:937-602-7530
Mailing Address - Fax:
Practice Address - Street 1:7817 N DIXIE DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45414-2719
Practice Address - Country:US
Practice Address - Phone:937-602-7530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-18
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant