Provider Demographics
NPI:1619996758
Name:WOODRUFF, SUSAN LYNN (ADULT NURSE PRACTITI)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:LYNN
Last Name:WOODRUFF
Suffix:
Gender:F
Credentials:ADULT NURSE PRACTITI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 HONEY TREE COURT
Mailing Address - Street 2:
Mailing Address - City:MIDWAY PARK
Mailing Address - State:NC
Mailing Address - Zip Code:28544-1642
Mailing Address - Country:US
Mailing Address - Phone:910-353-0235
Mailing Address - Fax:
Practice Address - Street 1:114C MEMORIAL DRIVE
Practice Address - Street 2:FAMILY CARE CLINIC
Practice Address - City:JAKCSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546
Practice Address - Country:US
Practice Address - Phone:910-353-7788
Practice Address - Fax:910-353-7498
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC900014363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7000362Medicaid
NC7000362Medicaid
2599188AMedicare ID - Type Unspecified