Provider Demographics
NPI:1477350981
Name:WOOTERS, MISTY DAWN
Entity type:Individual
Prefix:
First Name:MISTY
Middle Name:DAWN
Last Name:WOOTERS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 N 15TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROKEN BOW
Mailing Address - State:NE
Mailing Address - Zip Code:68822-1418
Mailing Address - Country:US
Mailing Address - Phone:308-880-0937
Mailing Address - Fax:
Practice Address - Street 1:412 N 15TH AVE
Practice Address - Street 2:
Practice Address - City:BROKEN BOW
Practice Address - State:NE
Practice Address - Zip Code:68822-1418
Practice Address - Country:US
Practice Address - Phone:308-880-0937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-03
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No372600000XNursing Service Related ProvidersAdult Companion
No171M00000XOther Service ProvidersCase Manager/Care Coordinator