Provider Demographics
NPI:1558343269
Name:WOODALL, DENISE (CRNA)
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:
Last Name:WOODALL
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 525
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-0525
Mailing Address - Country:US
Mailing Address - Phone:770-979-9996
Mailing Address - Fax:
Practice Address - Street 1:2151 FOUNTAIN DR
Practice Address - Street 2:SUITE 101
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-6783
Practice Address - Country:US
Practice Address - Phone:770-979-9996
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2013-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN139540367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA197715386AMedicaid
GAQ10229Medicare UPIN
GA197715386AMedicaid