Healthcare Provider Details

I. General information

NPI: 1821475245
Provider Name (Legal Business Name): MARY D WITTE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2015
Last Update Date: 09/10/2020
Certification Date: 09/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9436 SAINT MATHIAS RD
BRAINERD MN
56401-5165
US

IV. Provider business mailing address

649KENILWORTH AVE
DULUTH MN
55803
US

V. Phone/Fax

Practice location:
  • Phone: 218-855-1004
  • Fax:
Mailing address:
  • Phone: 218-820-6506
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR-103555-3
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: