Provider Demographics
NPI:1295984755
Name:WOOTEN, SAMYRA RENEE (PT)
Entity type:Individual
Prefix:
First Name:SAMYRA
Middle Name:RENEE
Last Name:WOOTEN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:SAMYRA
Other - Middle Name:RENNE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:3700 SYMI CIR
Mailing Address - Street 2:
Mailing Address - City:MOREHEAD CITY
Mailing Address - State:NC
Mailing Address - Zip Code:28557-4309
Mailing Address - Country:US
Mailing Address - Phone:252-247-2738
Mailing Address - Fax:252-240-3882
Practice Address - Street 1:2828 MAPLEWOOD AVE
Practice Address - Street 2:STE A
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-4138
Practice Address - Country:US
Practice Address - Phone:336-765-4703
Practice Address - Fax:336-765-1396
Is Sole Proprietor?:No
Enumeration Date:2008-09-09
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11523225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist