Healthcare Provider Details

I. General information

NPI: 1447645379
Provider Name (Legal Business Name): BETHANY WOOTEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2015
Last Update Date: 01/14/2021
Certification Date: 01/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3917 WEST RD
LOS ALAMOS NM
87544-2275
US

IV. Provider business mailing address

860 ASTER ST
LOS ALAMOS NM
87547-3869
US

V. Phone/Fax

Practice location:
  • Phone: 573-686-5550
  • Fax:
Mailing address:
  • Phone: 573-686-5550
  • Fax: 573-686-2139

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2015013955
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: