Healthcare Provider Details

I. General information

NPI: 1366836082
Provider Name (Legal Business Name): TIFFANI WITMON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2015
Last Update Date: 06/17/2020
Certification Date: 06/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

59 PAGE HILL RD
BERLIN NH
03570-3531
US

IV. Provider business mailing address

59 PAGE HILL RD
BERLIN NH
03570-3531
US

V. Phone/Fax

Practice location:
  • Phone: 603-752-2200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YX0602X
TaxonomyOtolaryngic Allergy Physician
License Number1083
License Number StateNH
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: