Provider Demographics
NPI:1558763698
Name:WOOLDRIDGE, LANETIA
Entity Type:Individual
Prefix:
First Name:LANETIA
Middle Name:
Last Name:WOOLDRIDGE
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 1:13313 N ETNA GREEN DR
Mailing Address - Street 2:
Mailing Address - City:CAMBY
Mailing Address - State:IN
Mailing Address - Zip Code:46113-8351
Mailing Address - Country:US
Mailing Address - Phone:317-319-8092
Mailing Address - Fax:
Practice Address - Street 1:13313 N ETNA GREEN DR
Practice Address - Street 2:
Practice Address - City:CAMBY
Practice Address - State:IN
Practice Address - Zip Code:46113-8351
Practice Address - Country:US
Practice Address - Phone:317-319-8092
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-19
Last Update Date:2014-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker