Provider Demographics
NPI:1154505709
Name:WOODARD, WACHENA (MA 43333)
Entity Type:Individual
Prefix:
First Name:WACHENA
Middle Name:
Last Name:WOODARD
Suffix:
Gender:F
Credentials:MA 43333
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 311838
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33680-3838
Mailing Address - Country:US
Mailing Address - Phone:813-732-0992
Mailing Address - Fax:
Practice Address - Street 1:1109 N PARSONS AVE
Practice Address - Street 2:STE 108 MM21961
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33510-3105
Practice Address - Country:US
Practice Address - Phone:813-732-0992
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-18
Last Update Date:2008-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA43333225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist