=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790753382
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PHYLLIS M WOODSON RD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/09/2006
-----------------------------------------------------
Last Update Date | 08/05/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 855 W BRAMBLETON AVE
-----------------------------------------------------
City | NORFOLK
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23510-1005
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-446-5908
-----------------------------------------------------
Fax | 757-446-7055
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 936
-----------------------------------------------------
City | NORFOLK
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23501-0936
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-446-5908
-----------------------------------------------------
Fax | 757-446-7055
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 133V00000X
-----------------------------------------------------
Taxonomy Name | Registered Dietitian
-----------------------------------------------------
License Number | R37612-2
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------