Basic Information
| Provider Information | |||||||||
| NPI: | 1114568607 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WOOD | ||||||||
| FirstName: | GEORGENE | ||||||||
| MiddleName: | CLEMENTS | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | N.P. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CLEMENTS | ||||||||
| OtherFirstName: | MARY | ||||||||
| OtherMiddleName: | GEORGENE | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 417 N. 11TH ST. | ||||||||
| Address2: | 5TH FLOOR | ||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 23298 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8046286658 | ||||||||
| FaxNumber: | 8048271744 | ||||||||
| Practice Location | |||||||||
| Address1: | 417 N. 11TH ST. | ||||||||
| Address2: | 5TH FLOOR | ||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 23298 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8046286658 | ||||||||
| FaxNumber: | 8048271744 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2019 | ||||||||
| LastUpdateDate: | 09/29/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 0024177925 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.