Healthcare Provider Details

I. General information

NPI: 1851910236
Provider Name (Legal Business Name): MRS. OLETHA G WELLON-DAMES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2020
Last Update Date: 04/15/2020
Certification Date: 04/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

139 BOB THOMAS CIR
SANFORD FL
32771-3096
US

IV. Provider business mailing address

139 BOB THOMAS CIR
SANFORD FL
32771-3096
US

V. Phone/Fax

Practice location:
  • Phone: 407-820-4133
  • Fax:
Mailing address:
  • Phone: 407-820-4133
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number00125
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License NumberD520
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: