Basic Information
Provider Information
NPI: 1003141235
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: WOOD
FirstName: GLORIA
MiddleName: DENISE
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName: WOOD
OtherFirstName: GLORIA
OtherMiddleName: DENISE
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential: LPN
OtherLastNameType: 2
Mailing Information
Address1: 30 PARKER AVE
Address2:  
City: POUGHKEEPSIE
State: NY
PostalCode: 126011927
CountryCode: US
TelephoneNumber: 8455050598
FaxNumber:  
Practice Location
Address1: 30 PARKER AVE
Address2:  
City: POUGHKEEPSIE
State: NY
PostalCode: 126011927
CountryCode: US
TelephoneNumber: 8455050598
FaxNumber:  
Other Information
ProviderEnumerationDate: 10/06/2009
LastUpdateDate: 10/06/2009
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
164W00000X268273-1NYY Nursing Service ProvidersLicensed Practical Nurse 

No ID Information.


Home