Provider Demographics
NPI:1578713285
Name:WOOTEN, AMY DANIELLE (PTA)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:DANIELLE
Last Name:WOOTEN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:142 BERMUDA VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:ADVANCE
Mailing Address - State:NC
Mailing Address - Zip Code:27006-7867
Mailing Address - Country:US
Mailing Address - Phone:336-940-6433
Mailing Address - Fax:
Practice Address - Street 1:142 BERMUDA VILLAGE DR
Practice Address - Street 2:
Practice Address - City:ADVANCE
Practice Address - State:NC
Practice Address - Zip Code:27006-7867
Practice Address - Country:US
Practice Address - Phone:336-940-6433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-30
Last Update Date:2008-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2530225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant