Provider Demographics
NPI:1962782219
Name:WOODARD, MONIQUE NICOLE
Entity type:Individual
Prefix:MS
First Name:MONIQUE
Middle Name:NICOLE
Last Name:WOODARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 3300
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32315-3300
Mailing Address - Country:US
Mailing Address - Phone:850-322-3590
Mailing Address - Fax:
Practice Address - Street 1:1928 CHARLAIS ST
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32317-8406
Practice Address - Country:US
Practice Address - Phone:850-322-3590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-18
Last Update Date:2011-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL74030172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver