Provider Demographics
NPI:1659576494
Name:WOODHAM, JILL D (CRNP)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:D
Last Name:WOODHAM
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:JILL
Other - Last Name:DANSBY WOODHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1118 ROSS CLARK CIR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36301-3001
Mailing Address - Country:US
Mailing Address - Phone:334-794-1148
Mailing Address - Fax:334-793-1954
Practice Address - Street 1:1118 ROSS CLARK CIR
Practice Address - Street 2:SUITE 100
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-3001
Practice Address - Country:US
Practice Address - Phone:334-794-1148
Practice Address - Fax:334-793-1954
Is Sole Proprietor?:No
Enumeration Date:2007-06-20
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1049498363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51544862Medicare PIN