=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942817838
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EBONY SYMONE' WOODSON FNP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/25/2020
-----------------------------------------------------
Last Update Date | 08/25/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8613 MS HIGHWAY 12
-----------------------------------------------------
City | ACKERMAN
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39735-8917
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-285-4000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8613 MS HIGHWAY 12
-----------------------------------------------------
City | ACKERMAN
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39735-8917
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-285-4000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 904386
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------