1467843052 NPI number — MRS. MUNTRELLA REGINA WOODARD MASTERS OF ART

Table of content: MRS. MUNTRELLA REGINA WOODARD MASTERS OF ART (NPI 1467843052)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467843052 NPI number — MRS. MUNTRELLA REGINA WOODARD MASTERS OF ART

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WOODARD
Provider First Name:
MUNTRELLA
Provider Middle Name:
REGINA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MASTERS OF ART
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FORBES
Provider Other First Name:
MUNTRELLA
Provider Other Middle Name:
REGINA
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MASTERS OF SCIENCE
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1467843052
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/18/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
735 N CYPRESS AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREEN COVE SPRINGS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32043-2412
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-600-1349
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
580 ELLIS RD S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32254-3582
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-423-0017
Provider Business Practice Location Address Fax Number:
904-683-8169
Provider Enumeration Date:
02/18/2015

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: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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