Healthcare Provider Details

I. General information

NPI: 1124956289
Provider Name (Legal Business Name): IRACY MIGUELINA WOOTEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2026
Last Update Date: 05/11/2026
Certification Date: 05/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1317 THE TER
HAGERSTOWN MD
21742-3231
US

IV. Provider business mailing address

1317 THE TER
HAGERSTOWN MD
21742-3231
US

V. Phone/Fax

Practice location:
  • Phone: 301-257-7017
  • Fax:
Mailing address:
  • Phone: 301-257-7017
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberR230403
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: