MEDICARE: MS. SHAMARIA LATRICE WOOTEN-BOSTON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	200549	WI
2	363LF0000X	Family Nurse Practitioner	14971	WI

General Provider Information

NPI Number	:	1467817676
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SHAMARIA LATRICE WOOTEN-BOSTON

Provider Business Mailing Address
First Line	:	8661 N PORT WASHINGTON RD
Second Line	:
City	:	FOX POINT
State	:	WI
Zip	:	53217-2209
Country	:	US
Telephone Number	:	866-389-2727
Fax Number	:

Provider Business Practice Location Address
First Line	:	8661 N PORT WASHINGTON RD
Second Line	:
City	:	FOX POINT
State	:	WI
Zip	:	53217-2209
Country	:	US
Telephone Number	:	866-389-2727
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/15/2015
Last Update Date	:	09/11/2024

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