Healthcare Provider Details

I. General information

NPI: 1659116408
Provider Name (Legal Business Name): BROCK ALAN WOOTEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2024
Last Update Date: 01/08/2026
Certification Date: 01/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2111 N NORTHGATE WAY STE 216
SEATTLE WA
98133-9018
US

IV. Provider business mailing address

2111 N NORTHGATE WAY STE 216
SEATTLE WA
98133-9018
US

V. Phone/Fax

Practice location:
  • Phone: 206-385-9636
  • Fax:
Mailing address:
  • Phone: 206-385-9636
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP70035795
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN.CNP.0036699
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: