Basic Information
| Provider Information | |||||||||
| NPI: | 1790753382 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WOODSON | ||||||||
| FirstName: | PHYLLIS | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 936 | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235010936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574465908 | ||||||||
| FaxNumber: | 7574467055 | ||||||||
| Practice Location | |||||||||
| Address1: | 855 W BRAMBLETON AVE | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235101005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574465908 | ||||||||
| FaxNumber: | 7574467055 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2006 | ||||||||
| LastUpdateDate: | 08/05/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | R37612-2 | VA | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 2116995 | 01 | VA | UHC/MAMSI | OTHER | PAR | 01 | VA | VIRGINIA PREMIER HEALTH | OTHER | PAR | 01 | VA | CORVEL/CORCARE | OTHER | 1790753382 | 05 | VA | MEDICAID | PAR | 01 | VA | MUTLIPLAN | OTHER | PAR | 01 | VA | AETNA | OTHER | -033 | 01 | VA | TRICARE/CHAMPUS | OTHER |