Healthcare Provider Details

I. General information

NPI: 1861912149
Provider Name (Legal Business Name): MRS. MICHELLE WOODWORTH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2017
Last Update Date: 08/13/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

802 LANDMARK DR. STE 119
GLEN BURNIE MD
21061
US

IV. Provider business mailing address

802 LANDMARK DR STE 119
GLEN BURNIE MD
21061
US

V. Phone/Fax

Practice location:
  • Phone: 410-760-8840
  • Fax: 410-367-2464
Mailing address:
  • Phone: 410-760-8840
  • Fax: 410-760-8847

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number02789
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: