Healthcare Provider Details

I. General information

NPI: 1043724180
Provider Name (Legal Business Name): NICOLE ALANNA WOODARD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/28/2017
Last Update Date: 03/25/2022
Certification Date: 03/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 W CENTRAL PARK AVE FL 4
DAVENPORT IA
52804-1707
US

IV. Provider business mailing address

628 VALLEY VIEW DR
SILVIS IL
61282-1748
US

V. Phone/Fax

Practice location:
  • Phone: 563-421-1000
  • Fax:
Mailing address:
  • Phone: 309-644-1090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number62557
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number099279
License Number StateIA
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number294973
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070022424
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: