Provider Demographics
NPI:1851899454
Name:WOOTON, NICHOLE MARIE
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:MARIE
Last Name:WOOTON
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 1:1115 HARBOR RD
Mailing Address - Street 2:
Mailing Address - City:GROVE
Mailing Address - State:OK
Mailing Address - Zip Code:74344-3505
Mailing Address - Country:US
Mailing Address - Phone:918-786-4434
Mailing Address - Fax:918-786-4435
Practice Address - Street 1:1115 HAR-BER ROAD
Practice Address - Street 2:
Practice Address - City:GROVE
Practice Address - State:OK
Practice Address - Zip Code:74344
Practice Address - Country:US
Practice Address - Phone:864-353-6030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-29
Last Update Date:2018-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator