Healthcare Provider Details

I. General information

NPI: 1528620028
Provider Name (Legal Business Name): KIYA KATHRYN DEWITT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2019
Last Update Date: 07/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 RIDGEWOOD DR
PITTSBURG NH
03592-5219
US

IV. Provider business mailing address

317 N 6TH ST APT 5
ALLENTOWN PA
18102-3335
US

V. Phone/Fax

Practice location:
  • Phone: 603-331-5024
  • Fax:
Mailing address:
  • Phone: 603-331-5024
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: