Healthcare Provider Details

I. General information

NPI: 1770585796
Provider Name (Legal Business Name): NANCY WITHAM M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2005
Last Update Date: 10/01/2021
Certification Date: 10/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1140 PRATT BLVD
LABELLE FL
33935-4405
US

IV. Provider business mailing address

PO BOX 70
LABELLE FL
33975-0070
US

V. Phone/Fax

Practice location:
  • Phone: 863-674-4041
  • Fax:
Mailing address:
  • Phone: 863-674-4041
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME63344
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: