Basic Information
| Provider Information | |||||||||
| NPI: | 1003150616 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WOODARD | ||||||||
| FirstName: | EVELEAN | ||||||||
| MiddleName: | DAVIS | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DAVIS | ||||||||
| OtherFirstName: | EVELEAN | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 112 AKINS LN | ||||||||
| Address2: | |||||||||
| City: | MANSON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275539124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2524562128 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 112 AKINS LN | ||||||||
| Address2: | |||||||||
| City: | MANSON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275539124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2524562128 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2012 | ||||||||
| LastUpdateDate: | 11/20/2012 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171W00000X | MHL-093-040 | NC | Y | Other Service Providers | Contractor |
No ID Information.