Healthcare Provider Details

I. General information

NPI: 1629120878
Provider Name (Legal Business Name): MARYBETH WITCHER F.N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 06/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 STURDY RD
VALPARAISO IN
46383-4126
US

IV. Provider business mailing address

951 TRANSPORT DR
VALPARAISO IN
46383-8434
US

V. Phone/Fax

Practice location:
  • Phone: 219-462-7173
  • Fax: 219-462-7504
Mailing address:
  • Phone: 219-477-6082
  • Fax: 219-465-9502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71000341A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: