Basic Information
| Provider Information | |||||||||
| NPI: | 1295984755 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WOOTEN | ||||||||
| FirstName: | SAMYRA | ||||||||
| MiddleName: | RENEE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JOHNSON | ||||||||
| OtherFirstName: | SAMYRA | ||||||||
| OtherMiddleName: | RENNE | ||||||||
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| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3700 SYMI CIR | ||||||||
| Address2: | |||||||||
| City: | MOREHEAD CITY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285574309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2522472738 | ||||||||
| FaxNumber: | 2522403882 | ||||||||
| Practice Location | |||||||||
| Address1: | 2828 MAPLEWOOD AVE | ||||||||
| Address2: | STE A | ||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271034138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367654703 | ||||||||
| FaxNumber: | 3367651396 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2008 | ||||||||
| LastUpdateDate: | 09/09/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 11523 | NC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.