Healthcare Provider Details

I. General information

NPI: 1932770948
Provider Name (Legal Business Name): MICKIE DAVINA WOODALL PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2021
Last Update Date: 07/09/2021
Certification Date: 07/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 CHRISTIAN LN
SLIDELL LA
70458-1377
US

IV. Provider business mailing address

2900 INDIANA AVE
KENNER LA
70065-4605
US

V. Phone/Fax

Practice location:
  • Phone: 504-575-3712
  • Fax:
Mailing address:
  • Phone: 504-575-3712
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number221224
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: