Provider Demographics
NPI:1093260176
Name:WOODLAKE PODIATRY, LLC
Entity Type:Organization
Organization Name:WOODLAKE PODIATRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHERYL
Authorized Official - Middle Name:
Authorized Official - Last Name:HANAWALT
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:314-434-7430
Mailing Address - Street 1:222 S WOODS MILL RD # 440N
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-3625
Mailing Address - Country:US
Mailing Address - Phone:314-434-7430
Mailing Address - Fax:314-434-8768
Practice Address - Street 1:222 S WOODS MILL RD STE 440N
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-3625
Practice Address - Country:US
Practice Address - Phone:314-434-7430
Practice Address - Fax:314-434-8768
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-18
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015014632213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty