Healthcare Provider Details

I. General information

NPI: 1730257213
Provider Name (Legal Business Name): NANCY J WITTSTOCK CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 W UNIVERSITY DR
ROCHESTER MI
48307-1863
US

IV. Provider business mailing address

26360 VINCENNES AVE
FRANKLIN MI
48025-1756
US

V. Phone/Fax

Practice location:
  • Phone: 248-652-5354
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704063537
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: