Healthcare Provider Details

I. General information

NPI: 1417000878
Provider Name (Legal Business Name): REBECCA L WITTENBURG CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2007
Last Update Date: 12/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 OAK ST NE 300
ALBUQUERQUE NM
87106-4725
US

IV. Provider business mailing address

300 OAK ST NE
ALBUQUERQUE NM
87106-4725
US

V. Phone/Fax

Practice location:
  • Phone: 505-855-5525
  • Fax: 505-884-4006
Mailing address:
  • Phone: 505-855-5525
  • Fax: 505-884-4006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR21445
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: