Healthcare Provider Details

I. General information

NPI: 1487226528
Provider Name (Legal Business Name): KRISTIN WITHERS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2021
Last Update Date: 07/16/2021
Certification Date: 06/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

GATEWAY HEALTH PLAN 444 LIBERTY AVE
PITTSBURGH PA
15222-1222
US

IV. Provider business mailing address

364 GREENE DR
JEFFERSON HILLS PA
15025-6315
US

V. Phone/Fax

Practice location:
  • Phone: 412-965-7361
  • Fax:
Mailing address:
  • Phone: 412-965-7361
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH069302
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: