Provider Demographics
NPI:1811253396
Name:WELLS, DEIDRA NICOLE (DC)
Entity type:Individual
Prefix:DR
First Name:DEIDRA
Middle Name:NICOLE
Last Name:WELLS
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:DEIDRA
Other - Middle Name:NICOLE
Other - Last Name:MOODY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:1272 HOUNDSLAKE DR
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30008-8715
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6196 OXON HILL RD STE 125
Practice Address - Street 2:
Practice Address - City:OXON HILL
Practice Address - State:MD
Practice Address - Zip Code:20745
Practice Address - Country:US
Practice Address - Phone:301-753-7970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-09
Last Update Date:2019-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR008906111N00000X
MDS04035111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor