Provider Demographics
NPI:1639714447
Name:WOODRUFF, PAMELA JEAN
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:JEAN
Last Name:WOODRUFF
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 1:5259 DISCOVERY DR SE
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49508-6394
Mailing Address - Country:US
Mailing Address - Phone:616-886-6119
Mailing Address - Fax:
Practice Address - Street 1:4450 CASCADE RD SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-3633
Practice Address - Country:US
Practice Address - Phone:616-949-5140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-15
Last Update Date:2019-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201001692225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist