Provider Demographics
NPI:1871676742
Name:WOOTTEN, TERRELL (CNM)
Entity Type:Individual
Prefix:
First Name:TERRELL
Middle Name:
Last Name:WOOTTEN
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:TERRELL
Other - Middle Name:
Other - Last Name:O'STEEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNM
Mailing Address - Street 1:PO BOX 623
Mailing Address - Street 2:
Mailing Address - City:SOUTH HILL
Mailing Address - State:VA
Mailing Address - Zip Code:23970-0623
Mailing Address - Country:US
Mailing Address - Phone:434-447-7765
Mailing Address - Fax:434-447-2845
Practice Address - Street 1:420 BRACEY LN
Practice Address - Street 2:
Practice Address - City:SOUTH HILL
Practice Address - State:VA
Practice Address - Zip Code:23970-1631
Practice Address - Country:US
Practice Address - Phone:434-447-7765
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2014-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024056113367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0024056113OtherCNM VA LICENSE