Provider Demographics
NPI:1063130870
Name:WOODFORD, FALLON NICOLE
Entity type:Individual
Prefix:
First Name:FALLON
Middle Name:NICOLE
Last Name:WOODFORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:606 S OXFORD VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:FAIRLESS HILLS
Mailing Address - State:PA
Mailing Address - Zip Code:19030-3902
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5261 MARLTON PIKE
Practice Address - Street 2:
Practice Address - City:PENNSAUKEN
Practice Address - State:NJ
Practice Address - Zip Code:08109-4701
Practice Address - Country:US
Practice Address - Phone:724-201-6351
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-17
Last Update Date:2022-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR24311400163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)