Provider Demographics
NPI:1659116408
Name:WOOTEN, BROCK ALAN
Entity type:Individual
Prefix:
First Name:BROCK
Middle Name:ALAN
Last Name:WOOTEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 PROSPECT MOUNT VERNON RD W
Mailing Address - Street 2:
Mailing Address - City:WALDO
Mailing Address - State:OH
Mailing Address - Zip Code:43356-9116
Mailing Address - Country:US
Mailing Address - Phone:614-634-0304
Mailing Address - Fax:
Practice Address - Street 1:65 MESSIMER DR
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-1874
Practice Address - Country:US
Practice Address - Phone:740-522-8477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-25
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.0036699363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health