Healthcare Provider Details

I. General information

NPI: 1073716288
Provider Name (Legal Business Name): JENNIFER A WITTENAUER R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 E 6TH ST
LOVELAND CO
80537-5681
US

IV. Provider business mailing address

3364 LAREDO LN
FORT COLLINS CO
80526-4234
US

V. Phone/Fax

Practice location:
  • Phone: 970-679-4485
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number126248
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: