Provider Demographics
NPI:1134502388
Name:WOOTEN, STACY JEAN
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:JEAN
Last Name:WOOTEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:
Other - Last Name:HILL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6626 E 75TH ST STE 500
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2890
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9669 E 146TH ST STE 165
Practice Address - Street 2:
Practice Address - City:NOBLESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46060-5007
Practice Address - Country:US
Practice Address - Phone:317-621-6740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-07
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05012633A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist