Provider Demographics
NPI:1043724180
Name:WOODARD, NICOLE ALANNA
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ALANNA
Last Name:WOODARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:628 VALLEY VIEW DR
Mailing Address - Street 2:
Mailing Address - City:SILVIS
Mailing Address - State:IL
Mailing Address - Zip Code:61282-1748
Mailing Address - Country:US
Mailing Address - Phone:309-644-1090
Mailing Address - Fax:
Practice Address - Street 1:1401 W CENTRAL PARK AVE FL 4
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52804-1707
Practice Address - Country:US
Practice Address - Phone:563-421-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-28
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA099279225100000X
CA294973225100000X
OR62557261QP2000X
IL070022424225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy