Basic Information
| Provider Information | |||||||||
| NPI: | 1093165607 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GARRETT | ||||||||
| FirstName: | DYANDRA | ||||||||
| MiddleName: | |||||||||
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| OtherLastName: | HENDERSON | ||||||||
| OtherFirstName: | DYANDRA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4144 SPRINGBURN DR | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436156549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193564123 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6605 W CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436171000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4198417701 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2016 | ||||||||
| LastUpdateDate: | 06/14/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | PN115357 | OH | Y | Nursing Service Providers | Licensed Practical Nurse |
No ID Information.