Provider Demographics
NPI:1912770249
Name:WOOTEN, LADEIDRA NICOLE (RN)
Entity type:Individual
Prefix:
First Name:LADEIDRA
Middle Name:NICOLE
Last Name:WOOTEN
Suffix:
Gender:
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4250 ANTELOPE LN
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30039-5694
Mailing Address - Country:US
Mailing Address - Phone:770-778-1702
Mailing Address - Fax:
Practice Address - Street 1:4250 ANTELOPE LN
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30039-5694
Practice Address - Country:US
Practice Address - Phone:770-778-1702
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-30
Last Update Date:2025-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN243005163WC0400X, 101YP1600X, 163WP0808X, 171400000X, 171M00000X, 173C00000X, 174H00000X, 202D00000X
GAMT013436163WM1400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No163WM1400XNursing Service ProvidersRegistered NurseNurse Massage Therapist (NMT)
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No171400000XOther Service ProvidersHealth & Wellness Coach
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No173C00000XOther Service ProvidersReflexologist
No174H00000XOther Service ProvidersHealth Educator
No202D00000XAllopathic & Osteopathic PhysiciansIntegrative Medicine