1053955906 NPI number — MISS DINA BREANNE MAXINE WOODWORTH

Table of content: MISS DINA BREANNE MAXINE WOODWORTH (NPI 1053955906)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053955906 NPI number — MISS DINA BREANNE MAXINE WOODWORTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WOODWORTH
Provider First Name:
DINA
Provider Middle Name:
BREANNE MAXINE
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053955906
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/04/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2222 ROCKWOOD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELLEVILLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62221-6839
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-383-4381
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
634 N MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
O FALLON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62269-3751
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-726-0701
Provider Business Practice Location Address Fax Number:
224-210-1514
Provider Enumeration Date:
11/04/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103K00000X , with the licence number:  W363-1629-3972 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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