Healthcare Provider Details

I. General information

NPI: 1093621708
Provider Name (Legal Business Name): ALESA DAWN WITTMAN C-CHW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2026
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

408 W 4TH AVE
BRISTOW OK
74010-2702
US

IV. Provider business mailing address

408 W 4TH AVE
BRISTOW OK
74010-2702
US

V. Phone/Fax

Practice location:
  • Phone: 918-367-3341
  • Fax:
Mailing address:
  • Phone: 918-367-3341
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number202663
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: