Healthcare Provider Details

I. General information

NPI: 1558306761
Provider Name (Legal Business Name): SALLY M WOOTEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2006
Last Update Date: 02/08/2024
Certification Date: 02/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

927 KENTON STATION DR
MAYSVILLE KY
41056-9617
US

IV. Provider business mailing address

330 SEVEN SPRINGS WAY
BRENTWOOD TN
37027-5098
US

V. Phone/Fax

Practice location:
  • Phone: 606-759-0433
  • Fax: 606-759-0058
Mailing address:
  • Phone: 615-920-7906
  • Fax: 615-920-8938

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number46724
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number46724
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: