Provider Demographics
NPI:1780751933
Name:WOOTEN, LINDA FAY
Entity type:Individual
Prefix:MRS
First Name:LINDA
Middle Name:FAY
Last Name:WOOTEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2259 SPRING PLACE RD SE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37323
Mailing Address - Country:US
Mailing Address - Phone:423-559-8176
Mailing Address - Fax:423-559-9699
Practice Address - Street 1:2259 SPRING PLACE RD SE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37323
Practice Address - Country:US
Practice Address - Phone:423-559-8176
Practice Address - Fax:423-559-9699
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0066621172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4108705OtherBLUE CARE TENN CARE SELEC
TNT000174Medicaid