Healthcare Provider Details

I. General information

NPI: 1811329766
Provider Name (Legal Business Name): LOIS DOMINIQUE WOODSIDE CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2013
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3461 CIVIC CENTER BLVD
PHILADELPHIA PA
19104-4302
US

IV. Provider business mailing address

1 FEDERAL ST STE 200
CAMDEN NJ
08103-1088
US

V. Phone/Fax

Practice location:
  • Phone: 215-823-4526
  • Fax:
Mailing address:
  • Phone: 848-288-6935
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberRN614739
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN614739
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number26NJ15452500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: