Basic Information
Provider Information | |||||||||
NPI: | 1629362199 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WOODRUFF | ||||||||
FirstName: | MILDRED | ||||||||
MiddleName: | SUE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | APRN, BSN, MSN, FNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1505 DELAWARE AVE | ||||||||
Address2: |   | ||||||||
City: | FORT PIERCE | ||||||||
State: | FL | ||||||||
PostalCode: | 349503975 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7724611402 | ||||||||
FaxNumber: | 5618472306 | ||||||||
Practice Location | |||||||||
Address1: | 1505 DELAWARE AVE | ||||||||
Address2: |   | ||||||||
City: | FORT PIERCE | ||||||||
State: | FL | ||||||||
PostalCode: | 349503975 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7724611402 | ||||||||
FaxNumber: | 5618472306 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/02/2011 | ||||||||
LastUpdateDate: | 05/12/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 28196047A | IN | N |   | Nursing Service Providers | Registered Nurse |   | 363LW0102X | 3006942 | KY | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health | 363LF0000X | ARNP9244530 | FL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.