Provider Demographics
NPI:1801139183
Name:WOODS, SELETTA MONIQUE (STNA)
Entity type:Individual
Prefix:
First Name:SELETTA
Middle Name:MONIQUE
Last Name:WOODS
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 1:416 FERNDALE AVE
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44511-3206
Mailing Address - Country:US
Mailing Address - Phone:330-787-7879
Mailing Address - Fax:
Practice Address - Street 1:416 FERNDALE AVE
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44511-3206
Practice Address - Country:US
Practice Address - Phone:330-787-7879
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-04
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH00750873747P1801X
OH501093730406376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0075087Medicaid