Provider Demographics
NPI:1679037444
Name:WOODBERRY, LATRERA CAMPBELL (FNP)
Entity Type:Individual
Prefix:
First Name:LATRERA
Middle Name:CAMPBELL
Last Name:WOODBERRY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:LATRAE
Other - Middle Name:CAMPBELL
Other - Last Name:WOODBERRY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:FNP
Mailing Address - Street 1:2518 HIGHWAY 9 E
Mailing Address - Street 2:
Mailing Address - City:DILLON
Mailing Address - State:SC
Mailing Address - Zip Code:29536-6166
Mailing Address - Country:US
Mailing Address - Phone:843-841-5313
Mailing Address - Fax:
Practice Address - Street 1:2518 HIGHWAY 9 E
Practice Address - Street 2:
Practice Address - City:DILLON
Practice Address - State:SC
Practice Address - Zip Code:29536-6166
Practice Address - Country:US
Practice Address - Phone:843-841-5313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-25
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5015386363LF0000X
FL11017086363LF0000X
390200000X
SC22659363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program