Provider Demographics
NPI:1245056092
Name:WOODWARD, STEPHANIE NICOLE (LDO)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:NICOLE
Last Name:WOODWARD
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:NICOLE
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LDO
Mailing Address - Street 1:1050 REGIONAL PARK RD
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:VA
Mailing Address - Zip Code:24266-3712
Mailing Address - Country:US
Mailing Address - Phone:276-889-3717
Mailing Address - Fax:276-889-3735
Practice Address - Street 1:1050 REGIONAL PARK RD
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:VA
Practice Address - Zip Code:24266-3712
Practice Address - Country:US
Practice Address - Phone:276-889-3717
Practice Address - Fax:276-889-3735
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-26
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1101004266156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician