Provider Demographics
NPI:1194024307
Name:WOODEN, MAMIE M
Entity Type:Individual
Prefix:MISS
First Name:MAMIE
Middle Name:M
Last Name:WOODEN
Suffix:
Gender:F
Credentials:
Other - Prefix:MR
Other - First Name:MICHAEL
Other - Middle Name:C
Other - Last Name:WOODEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1107 BOXWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31906-2701
Mailing Address - Country:US
Mailing Address - Phone:706-563-7573
Mailing Address - Fax:706-565-5711
Practice Address - Street 1:1022 FISK AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31906-3435
Practice Address - Country:US
Practice Address - Phone:706-321-0365
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-28
Last Update Date:2024-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA10601095-1171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator