Provider Demographics
NPI:1366039315
Name:WOODBERRY, MATTIE
Entity Type:Individual
Prefix:
First Name:MATTIE
Middle Name:
Last Name:WOODBERRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6365 I 55 N
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39213-9742
Mailing Address - Country:US
Mailing Address - Phone:601-718-0021
Mailing Address - Fax:
Practice Address - Street 1:6365 I 55 N
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39213-9742
Practice Address - Country:US
Practice Address - Phone:601-718-0021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-23
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT880499163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse