Provider Demographics
NPI:1154095057
Name:WOOTEN, ANTOINETTE
Entity Type:Individual
Prefix:MRS
First Name:ANTOINETTE
Middle Name:
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 1:1233 LAKEVIEW COVE DR
Mailing Address - Street 2:
Mailing Address - City:GRAYSON
Mailing Address - State:GA
Mailing Address - Zip Code:30017-7916
Mailing Address - Country:US
Mailing Address - Phone:404-775-8044
Mailing Address - Fax:404-759-2550
Practice Address - Street 1:1233 LAKEVIEW COVE DR
Practice Address - Street 2:
Practice Address - City:GRAYSON
Practice Address - State:GA
Practice Address - Zip Code:30017-7916
Practice Address - Country:US
Practice Address - Phone:404-775-8044
Practice Address - Fax:404-759-2550
Is Sole Proprietor?:No
Enumeration Date:2021-08-04
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACN0030054335376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide