Basic Information
Provider Information | |||||||||
NPI: | 1750564985 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WOODWARD | ||||||||
FirstName: | AMY | ||||||||
MiddleName: | WHITE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | RN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WHITE | ||||||||
OtherFirstName: | AMY | ||||||||
OtherMiddleName: | LEE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 284 EXECUTIVE PARK DR | ||||||||
Address2: |   | ||||||||
City: | CONCORD | ||||||||
State: | NC | ||||||||
PostalCode: | 280251831 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7049391100 | ||||||||
FaxNumber: | 7049391173 | ||||||||
Practice Location | |||||||||
Address1: | 1190 W ROOSEVELT BLVD | ||||||||
Address2: |   | ||||||||
City: | MONROE | ||||||||
State: | NC | ||||||||
PostalCode: | 281102818 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7042966200 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/11/2007 | ||||||||
LastUpdateDate: | 04/29/2018 | ||||||||
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 | 163WP0808X | R89242 | SC | Y |   | Nursing Service Providers | Registered Nurse | Psych/Mental Health |
ID Information
ID | Type | State | Issuer | Description | 405127 | 05 | SC |   | MEDICAID |