Provider Demographics
NPI:1053046946
Name:WOOTEN, MADELINE JOELLE
Entity Type:Individual
Prefix:
First Name:MADELINE
Middle Name:JOELLE
Last Name:WOOTEN
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 1:345 ODESSA WAY
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001-8305
Mailing Address - Country:US
Mailing Address - Phone:270-816-4062
Mailing Address - Fax:
Practice Address - Street 1:2601 KENTUCKY AVE STE 102
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-3817
Practice Address - Country:US
Practice Address - Phone:270-538-9555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-23
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program