Provider Demographics
NPI:1902500937
Name:WOODSON, KEVIN JR (REGISTERED NURSE)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:
Last Name:WOODSON
Suffix:JR
Gender:M
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 VICTORIA LN
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39056-4031
Mailing Address - Country:US
Mailing Address - Phone:769-234-0770
Mailing Address - Fax:
Practice Address - Street 1:309 AIRPORT RD S STE B
Practice Address - Street 2:
Practice Address - City:PEARL
Practice Address - State:MS
Practice Address - Zip Code:39208-6678
Practice Address - Country:US
Practice Address - Phone:769-234-0770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-27
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS917703163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse