Healthcare Provider Details

I. General information

NPI: 1245496280
Provider Name (Legal Business Name): JAMIE LYNN VITTUM AU D., CCC-A
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2008
Last Update Date: 02/21/2021
Certification Date: 02/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6035 FAIRVIEW RD
CHARLOTTE NC
28210-3256
US

IV. Provider business mailing address

20325 N 51ST AVE STE 154
GLENDALE AZ
85308-4622
US

V. Phone/Fax

Practice location:
  • Phone: 704-295-3000
  • Fax:
Mailing address:
  • Phone: 623-900-4740
  • Fax: 623-900-4741

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number230002405A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number11297
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number8228
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: