Provider Demographics
NPI:1407128358
Name:WOOTEN, CHASTITY JOLENE
Entity Type:Individual
Prefix:
First Name:CHASTITY
Middle Name:JOLENE
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 1:700 OLD ALABAMA RD SW
Mailing Address - Street 2:
Mailing Address - City:MC DONALD
Mailing Address - State:TN
Mailing Address - Zip Code:37353-5855
Mailing Address - Country:US
Mailing Address - Phone:276-202-8138
Mailing Address - Fax:
Practice Address - Street 1:700 OLD ALABAMA RD SW
Practice Address - Street 2:
Practice Address - City:MC DONALD
Practice Address - State:TN
Practice Address - Zip Code:37353-5855
Practice Address - Country:US
Practice Address - Phone:276-202-8138
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-07
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000003856224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant