Provider Demographics
NPI:1417481813
Name:WOODALL, WILLEEN (COTA)
Entity Type:Individual
Prefix:
First Name:WILLEEN
Middle Name:
Last Name:WOODALL
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31790 US HIGHWAY 19 N
Mailing Address - Street 2:UNIT 252
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34684-3729
Mailing Address - Country:US
Mailing Address - Phone:850-843-5837
Mailing Address - Fax:
Practice Address - Street 1:31790 US HIGHWAY 19 N
Practice Address - Street 2:UNIT 252
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34684-3729
Practice Address - Country:US
Practice Address - Phone:850-843-5837
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-12
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA15811314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility