Provider Demographics
NPI:1114672052
Name:WOOLDRIDGE, MARK GABRIEL SR (LPN NURSE)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:GABRIEL
Last Name:WOOLDRIDGE
Suffix:SR
Gender:M
Credentials:LPN NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1385 SHANABROOK DR
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44313-5708
Mailing Address - Country:US
Mailing Address - Phone:330-329-4253
Mailing Address - Fax:
Practice Address - Street 1:1385 SHANABROOK DR
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44313-5708
Practice Address - Country:US
Practice Address - Phone:330-329-4253
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-18
Last Update Date:2022-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN107095164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse