1063746022 NPI number — CAROL G. FOUNTAIN WOOTEN M.A.

Table of content: CAROL G. FOUNTAIN WOOTEN M.A. (NPI 1063746022)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063746022 NPI number — CAROL G. FOUNTAIN WOOTEN M.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WOOTEN
Provider First Name:
CAROL
Provider Middle Name:
G. FOUNTAIN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.A.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063746022
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/29/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1709 LEGION RD
Provider Second Line Business Mailing Address:
SUITE 224
Provider Business Mailing Address City Name:
CHAPEL HILL
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27517-2375
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-928-3611
Provider Business Mailing Address Fax Number:
919-929-8006

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1709 LEGION RD
Provider Second Line Business Practice Location Address:
SUITE 224
Provider Business Practice Location Address City Name:
CHAPEL HILL
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27517-2375
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-928-3611
Provider Business Practice Location Address Fax Number:
919-929-8006
Provider Enumeration Date:
09/23/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 106H00000X , with the licence number:  6079A , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101Y00000X , with the licence number: 7939 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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