=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104638626
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WYVETTE DILLARD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/22/2025
-----------------------------------------------------
Last Update Date | 01/22/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1122 STEPHENS ST
-----------------------------------------------------
City | MARTINSVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24112-4100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 276-806-5791
-----------------------------------------------------
Fax | 276-336-4930
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1122 STEPHENS ST
-----------------------------------------------------
City | MARTINSVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24112-4100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 276-806-5791
-----------------------------------------------------
Fax | 276-336-4930
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number | 30015085250001
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------