Provider Demographics
NPI:1114513835
Name:WOOTEN, KEON LATRICE
Entity Type:Individual
Prefix:MS
First Name:KEON
Middle Name:LATRICE
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 1:779 TURKEY POINT DR
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32065-2596
Mailing Address - Country:US
Mailing Address - Phone:904-402-3398
Mailing Address - Fax:
Practice Address - Street 1:779 TURKEY POINT DR
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32065-2596
Practice Address - Country:US
Practice Address - Phone:904-402-3398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-16
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care