Provider Demographics
NPI:1497199582
Name:WOODALL, ANISA GREEN (CN, LMP)
Entity Type:Individual
Prefix:MRS
First Name:ANISA
Middle Name:GREEN
Last Name:WOODALL
Suffix:
Gender:F
Credentials:CN, LMP
Other - Prefix:
Other - First Name:ANISA
Other - Middle Name:RITA
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CN, LMP
Mailing Address - Street 1:13116 NE 70TH PL
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98033-8571
Mailing Address - Country:US
Mailing Address - Phone:425-576-5433
Mailing Address - Fax:
Practice Address - Street 1:13116 NE 70TH PL
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98033-8571
Practice Address - Country:US
Practice Address - Phone:425-576-5433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-19
Last Update Date:2015-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60313607225700000X
WANU60584285133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist