Provider Demographics
NPI:1538764428
Name:WOODBERRY, MIRANNDA NICOLE (LPN)
Entity type:Individual
Prefix:
First Name:MIRANNDA
Middle Name:NICOLE
Last Name:WOODBERRY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1925 WAYCREST DR SW APT 2201
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30331-8467
Mailing Address - Country:US
Mailing Address - Phone:850-590-5187
Mailing Address - Fax:
Practice Address - Street 1:1925 WAYCREST DR SW APT 2201
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30331-8467
Practice Address - Country:US
Practice Address - Phone:850-590-5187
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL5221742164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
0000000000OtherN/A