1619996758 NPI number — MS. SUSAN LYNN WOODRUFF ADULT NURSE PRACTITI

Table of content: MS. SUSAN LYNN WOODRUFF ADULT NURSE PRACTITI (NPI 1619996758)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619996758 NPI number — MS. SUSAN LYNN WOODRUFF ADULT NURSE PRACTITI

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WOODRUFF
Provider First Name:
SUSAN
Provider Middle Name:
LYNN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
ADULT NURSE PRACTITI
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:
1619996758
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
103 HONEY TREE COURT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIDWAY PARK
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28544-1642
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-353-0235
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
114C MEMORIAL DRIVE
Provider Second Line Business Practice Location Address:
FAMILY CARE CLINIC
Provider Business Practice Location Address City Name:
JAKCSONVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28546
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-353-7788
Provider Business Practice Location Address Fax Number:
910-353-7498
Provider Enumeration Date:
07/19/2006

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: 363L00000X , with the licence number:  900014 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7000362 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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