Provider Demographics
NPI:1619264520
Name:WOODHAM, CHANETTA LASHAN (CRNP)
Entity Type:Individual
Prefix:MRS
First Name:CHANETTA
Middle Name:LASHAN
Last Name:WOODHAM
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:MS
Other - First Name:CHANETTA
Other - Middle Name:LASHAN
Other - Last Name:PAYTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CRNP
Mailing Address - Street 1:1121 S BRANNON STAND RD
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36305-7367
Mailing Address - Country:US
Mailing Address - Phone:334-714-3302
Mailing Address - Fax:
Practice Address - Street 1:207 HAVEN DR
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-2919
Practice Address - Country:US
Practice Address - Phone:334-793-3319
Practice Address - Fax:334-793-2291
Is Sole Proprietor?:No
Enumeration Date:2011-06-30
Last Update Date:2017-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-098137363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily