Healthcare Provider Details

I. General information

NPI: 1104486729
Provider Name (Legal Business Name): CAROLINE WITEK M.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2019
Last Update Date: 06/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4641 FULTON DR NW
CANTON OH
44718-2384
US

IV. Provider business mailing address

4641 FULTON DR NW
CANTON OH
44718-2384
US

V. Phone/Fax

Practice location:
  • Phone: 330-433-6075
  • Fax:
Mailing address:
  • Phone: 330-433-6075
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: