Provider Demographics
NPI:1760649297
Name:WOOTEN, RAYNA LANE (MS, RD, LD)
Entity Type:Individual
Prefix:
First Name:RAYNA
Middle Name:LANE
Last Name:WOOTEN
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:RAYNA
Other - Middle Name:LANE
Other - Last Name:ROGIERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, RD, LD
Mailing Address - Street 1:8415 DRAGON ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78254-2420
Mailing Address - Country:US
Mailing Address - Phone:210-240-0230
Mailing Address - Fax:
Practice Address - Street 1:2200 BERGQUIST DR STE 1
Practice Address - Street 2:
Practice Address - City:LACKLAND AFB
Practice Address - State:TX
Practice Address - Zip Code:78236-9908
Practice Address - Country:US
Practice Address - Phone:210-240-0230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-21
Last Update Date:2009-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT07347133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXDT07347OtherLICENSE NUMBER