Provider Demographics
NPI:1679183412
Name:WOOTEN, ALEXANDRA GRACE
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:GRACE
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 1:5043 N VISSCHER ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98407-2112
Mailing Address - Country:US
Mailing Address - Phone:253-948-6236
Mailing Address - Fax:
Practice Address - Street 1:5043 N VISSCHER ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98407-2112
Practice Address - Country:US
Practice Address - Phone:253-948-6236
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-06
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAES60980014146N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic