Basic Information
| Provider Information | |||||||||
| NPI: | 1164708632 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILBURN | ||||||||
| FirstName: | DAYNA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 4 POWELL ST | ||||||||
| Address2: | |||||||||
| City: | CUTHBERT | ||||||||
| State: | GA | ||||||||
| PostalCode: | 398406043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2293102077 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2100 COMER AVE | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 319048725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7063230174 | ||||||||
| FaxNumber: | 7062563264 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2011 | ||||||||
| LastUpdateDate: | 10/28/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 172V00000X | Y | Other Service Providers | Community Health Worker |
No ID Information.