Provider Demographics
NPI:1912495573
Name:RIDDICK, WYNTER WYNETTE (HOMEHEALTH CARE PROV)
Entity Type:Individual
Prefix:MRS
First Name:WYNTER
Middle Name:WYNETTE
Last Name:RIDDICK
Suffix:
Gender:F
Credentials:HOMEHEALTH CARE PROV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Mailing Address - Street 1:4529 BOTANY PARK DR # 407
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-7775
Mailing Address - Country:US
Mailing Address - Phone:252-698-1505
Mailing Address - Fax:757-449-6323
Practice Address - Street 1:5752 ANDREA DR
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23518-5743
Practice Address - Country:US
Practice Address - Phone:252-698-1505
Practice Address - Fax:757-499-6323
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-28
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide