Healthcare Provider Details

I. General information

NPI: 1720994940
Provider Name (Legal Business Name): MARISA WOOTEN WHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2026
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2050 LEXINGTON RD
VERSAILLES KY
40383-1738
US

IV. Provider business mailing address

6012 LINDEN CIR
TAMARAC FL
33319-3019
US

V. Phone/Fax

Practice location:
  • Phone: 754-777-3145
  • Fax:
Mailing address:
  • Phone: 754-777-3145
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number9535484
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: