Provider Demographics
NPI:1063854537
Name:WOODARD, BRIAN (LPN)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:WOODARD
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:545 ROSEWOOD TRL
Mailing Address - Street 2:
Mailing Address - City:GRAYSON
Mailing Address - State:GA
Mailing Address - Zip Code:30017-1261
Mailing Address - Country:US
Mailing Address - Phone:770-861-6807
Mailing Address - Fax:770-674-4578
Practice Address - Street 1:545 ROSEWOOD TRL
Practice Address - Street 2:
Practice Address - City:GRAYSON
Practice Address - State:GA
Practice Address - Zip Code:30017-1261
Practice Address - Country:US
Practice Address - Phone:770-861-6807
Practice Address - Fax:770-674-4578
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-24
Last Update Date:2013-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN050736164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse