Healthcare Provider Details

I. General information

NPI: 1962506410
Provider Name (Legal Business Name): VALERIE M WITT PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: VALERIE M STARK PA

II. Dates (important events)

Enumeration Date: 09/12/2006
Last Update Date: 12/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

188 W INDUSTRIAL DR
ELMHURST IL
60126-1623
US

IV. Provider business mailing address

188 W INDUSTRIAL DR
ELMHURST IL
60126-1623
US

V. Phone/Fax

Practice location:
  • Phone: 630-410-9888
  • Fax: 630-941-8194
Mailing address:
  • Phone: 630-410-9888
  • Fax: 630-941-8194

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085002800
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: