Provider Demographics
NPI:1245797331
Name:WOOTEN, EDEN MICHELLE (APRN, FNP-C)
Entity Type:Individual
Prefix:
First Name:EDEN
Middle Name:MICHELLE
Last Name:WOOTEN
Suffix:
Gender:F
Credentials:APRN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 911230
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75391-1230
Mailing Address - Country:US
Mailing Address - Phone:972-997-8000
Mailing Address - Fax:972-234-0813
Practice Address - Street 1:7777 FOREST LN STE D-220
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230-2571
Practice Address - Country:US
Practice Address - Phone:972-566-7790
Practice Address - Fax:972-566-3034
Is Sole Proprietor?:No
Enumeration Date:2019-02-25
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP140670363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX395126101Medicaid
TX395126102Medicaid