MEDICARE: MRS. TERRI LYNN BOGLE WOOTTEN VATL,ATC

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	2255A2300X	Athletic Trainer	0126-000001	VA

General Provider Information

NPI Number	:	1942379094
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TERRI LYNN BOGLE WOOTTEN VATL,ATC

Provider Business Mailing Address
First Line	:	10803 PINE ST
Second Line	:
City	:	FAIRFAX
State	:	VA
Zip	:	22030-2821
Country	:	US
Telephone Number	:	703-279-1554
Fax Number	:	703-279-1554

Provider Business Practice Location Address
First Line	:	6600 LITTLE FALLS RD
Second Line	:
City	:	ARLINGTON
State	:	VA
Zip	:	22213-1211
Country	:	US
Telephone Number	:	703-538-3301
Fax Number	:

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

Provider Enumeration Date	:	11/06/2006
Last Update Date	:	07/08/2007

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