Provider Demographics
NPI:1538703020
Name:WOMACK, GREGORY CHARLES SR (LPN)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:CHARLES
Last Name:WOMACK
Suffix:SR
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 1:4929 WISE AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1418
Mailing Address - Country:US
Mailing Address - Phone:314-814-4388
Mailing Address - Fax:
Practice Address - Street 1:4929 WISE AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1418
Practice Address - Country:US
Practice Address - Phone:314-814-4388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-29
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012013815164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse