Provider Demographics
NPI:1710289533
Name:WOOTEN, LISA M (MT-BC)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:M
Last Name:WOOTEN
Suffix:
Gender:F
Credentials:MT-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-6038
Mailing Address - Country:US
Mailing Address - Phone:570-601-1630
Mailing Address - Fax:570-601-1631
Practice Address - Street 1:520 W 4TH ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-6038
Practice Address - Country:US
Practice Address - Phone:570-601-1630
Practice Address - Fax:570-601-1631
Is Sole Proprietor?:No
Enumeration Date:2010-11-30
Last Update Date:2010-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA08632174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist