Healthcare Provider Details

I. General information

NPI: 1245857259
Provider Name (Legal Business Name): KENDRA ROBERTA WITT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2020
Last Update Date: 12/12/2022
Certification Date: 10/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6719 ALVARADO RD STE 304
SAN DIEGO CA
92120-5265
US

IV. Provider business mailing address

6719 ALVARADO RD STE 308
SAN DIEGO CA
92120-5268
US

V. Phone/Fax

Practice location:
  • Phone: 619-344-6918
  • Fax:
Mailing address:
  • Phone: 619-344-6918
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: