Provider Demographics
NPI:1275892234
Name:WOODARD, RANDY DALE (LPN)
Entity Type:Individual
Prefix:MR
First Name:RANDY
Middle Name:DALE
Last Name:WOODARD
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5971 TERRACE PARK DR N
Mailing Address - Street 2:UNIT 108
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33709-1181
Mailing Address - Country:US
Mailing Address - Phone:727-742-8172
Mailing Address - Fax:
Practice Address - Street 1:5971 TERRACE PARK DR N
Practice Address - Street 2:UNIT 108
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33709-1181
Practice Address - Country:US
Practice Address - Phone:727-742-8172
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-11
Last Update Date:2012-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPN 5185890164W00000X
NY219819-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse