Provider Demographics
NPI:1164040036
Name:WOODINGTON, KENNETH KEITH (APRN)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:KEITH
Last Name:WOODINGTON
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:KENNETH
Other - Middle Name:KEITH
Other - Last Name:BULLINGTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:556 SCOTT CIR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-4723
Mailing Address - Country:US
Mailing Address - Phone:678-710-5841
Mailing Address - Fax:
Practice Address - Street 1:556 SCOTT CIR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-4723
Practice Address - Country:US
Practice Address - Phone:678-710-5841
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-08
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN238883207RC0200X, 163W00000X, 208M00000X, 363LA2100X, 363LC0200X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No163W00000XNursing Service ProvidersRegistered Nurse
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LC0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARN238883OtherRN / APRN