Provider Demographics
NPI:1811257793
Name:WOOTEN, SAFIYA JENKINS (MPH RD LD)
Entity type:Individual
Prefix:
First Name:SAFIYA
Middle Name:JENKINS
Last Name:WOOTEN
Suffix:
Gender:F
Credentials:MPH RD LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1150 VARNUM ST NE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20017-2104
Mailing Address - Country:US
Mailing Address - Phone:202-269-7154
Mailing Address - Fax:
Practice Address - Street 1:913 E 26TH STREET , PIPER BUILDING SUITE 401
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407
Practice Address - Country:US
Practice Address - Phone:612-863-7501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-24
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3948133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered