Healthcare Provider Details

I. General information

NPI: 1215900170
Provider Name (Legal Business Name): MARY LOUISE WOOLDRIDGE MSN, APRN, BC
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

433 AEROSPACE MEDICINE SQUADRON 203 GALAXY RD SUITE 106
LACKLAND AIR FORCE BASE TX
78236-0112
US

IV. Provider business mailing address

WILFORD HALL MEDICAL CENTER ATTN: CREDENTIALS (CMC) 2200 BERGQUIST DRIVE SUITE 1
LACKLAND AFB TX
78236-5300
US

V. Phone/Fax

Practice location:
  • Phone: 210-925-5341
  • Fax:
Mailing address:
  • Phone: 210-925-5341
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: