Provider Demographics
NPI:1922529114
Name:WOOTEN, GRACE (MD)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:WOOTEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2511 86TH ST
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79423-3387
Mailing Address - Country:US
Mailing Address - Phone:806-793-5683
Mailing Address - Fax:844-522-0356
Practice Address - Street 1:2511 86TH ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79423-3387
Practice Address - Country:US
Practice Address - Phone:806-793-5683
Practice Address - Fax:844-522-0356
Is Sole Proprietor?:No
Enumeration Date:2017-06-28
Last Update Date:2021-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXT06762084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program