Provider Demographics
NPI:1811329766
Name:WOODSIDE, LOIS DOMINIQUE (CRNP)
Entity type:Individual
Prefix:
First Name:LOIS
Middle Name:DOMINIQUE
Last Name:WOODSIDE
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3461 CIVIC CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-4302
Mailing Address - Country:US
Mailing Address - Phone:215-823-4526
Mailing Address - Fax:
Practice Address - Street 1:3461 CIVIC CENTER BLVD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4302
Practice Address - Country:US
Practice Address - Phone:215-823-4526
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-02
Last Update Date:2015-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN614739363L00000X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care