MEDICARE: DR. ALICIA ELLEN WOOTEN AU.D.

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	231H00000X	Audiologist	2014035188	MO

General Provider Information

NPI Number	:	1760888218
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ALICIA ELLEN WOOTEN AU.D.

Provider Business Mailing Address
First Line	:	620 WALTON DR
Second Line	:
City	:	FARMINGTON
State	:	MO
Zip	:	63640-1935
Country	:	US
Telephone Number	:	573-756-0500
Fax Number	:	573-756-0505

Provider Business Practice Location Address
First Line	:	620 WALTON DR
Second Line	:
City	:	FARMINGTON
State	:	MO
Zip	:	63640-1935
Country	:	US
Telephone Number	:	573-756-0500
Fax Number	:	573-756-0505

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

Provider Enumeration Date	:	11/11/2014
Last Update Date	:	11/11/2014

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Directions to “ DR. ALICIA ELLEN WOOTEN AU.D.” Practice Location

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