=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538881503
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAKIMBERELY SHAJUAN WOOTEN APRN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/15/2022
-----------------------------------------------------
Last Update Date | 09/26/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 103 N MAIN ST
-----------------------------------------------------
City | LINDALE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75771-3115
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-882-3194
-----------------------------------------------------
Fax | 903-882-7405
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4002 TECHNOLOGY CTR
-----------------------------------------------------
City | LONGVIEW
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75605-2697
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-247-0484
-----------------------------------------------------
Fax | 903-247-0485
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 1037698
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------