Healthcare Provider Details

I. General information

NPI: 1184676777
Provider Name (Legal Business Name): VICKIE A. WOODS-MODELAND PNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 08/29/2023
Certification Date: 08/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 E DAVIS ST STE. A
CONROE TX
77301-3018
US

IV. Provider business mailing address

301 UNIVERSITY BLVD
GALVESTON TX
77555-5302
US

V. Phone/Fax

Practice location:
  • Phone: 936-525-2800
  • Fax: 936-539-4668
Mailing address:
  • Phone: 409-772-2222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number239394
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: