Healthcare Provider Details

I. General information

NPI: 1598200339
Provider Name (Legal Business Name): DEVAN WELLINGTON DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2017
Last Update Date: 12/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8402 CENTENNIAL PKWY
LAS VEGAS NV
89149-4792
US

IV. Provider business mailing address

8402 CENTENNIAL PKWY
LAS VEGAS NV
89149-4792
US

V. Phone/Fax

Practice location:
  • Phone: 702-731-1616
  • Fax: 702-294-7494
Mailing address:
  • Phone: 702-731-1616
  • Fax: 702-294-7494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number3457
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: