Healthcare Provider Details

I. General information

NPI: 1720797657
Provider Name (Legal Business Name): EMILY RENEE WITTENBERG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2022
Last Update Date: 03/25/2025
Certification Date: 03/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

702 SUNSET DR
ONTARIO OR
97914-3121
US

IV. Provider business mailing address

702 SUNSET DR
ONTARIO OR
97914-3121
US

V. Phone/Fax

Practice location:
  • Phone: 541-889-9167
  • Fax: 541-889-7873
Mailing address:
  • Phone: 541-889-9167
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number10006239
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number10006239
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number10006239
License Number StateOR
# 4
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number202113193RN
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: