MEDICARE: MRS. DYANNA WOOTEN

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	174H00000X	Health Educator

General Provider Information

NPI Number	:	1891033718
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. DYANNA WOOTEN

Provider Business Mailing Address
First Line	:	4302 E RAY RD
Second Line	:	SUITE 107
City	:	PHOENIX
State	:	AZ
Zip	:	85044-4706
Country	:	US
Telephone Number	:	888-535-7341
Fax Number	:	480-753-0964

Provider Business Practice Location Address
First Line	:	4302 E RAY RD
Second Line	:	SUITE 107
City	:	PHOENIX
State	:	AZ
Zip	:	85044-4706
Country	:	US
Telephone Number	:	888-535-7341
Fax Number	:	480-753-0964

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

Provider Enumeration Date	:	01/28/2013
Last Update Date	:	01/28/2013

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