Provider Demographics
NPI:1700119203
Name:WOODBERRY, JUANITA THERESA (STNA)
Entity Type:Individual
Prefix:
First Name:JUANITA
Middle Name:THERESA
Last Name:WOODBERRY
Suffix:
Gender:F
Credentials:STNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3632 TORWOOD RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43232-6021
Mailing Address - Country:US
Mailing Address - Phone:614-515-8044
Mailing Address - Fax:
Practice Address - Street 1:3632 TORWOOD RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43232-6021
Practice Address - Country:US
Practice Address - Phone:614-515-8044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-15
Last Update Date:2009-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH400806330908171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor