Healthcare Provider Details

I. General information

NPI: 1508296401
Provider Name (Legal Business Name): NANCY WYTOVICH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2013
Last Update Date: 11/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

497 1ST ST
PORT CARBON PA
17965-1623
US

IV. Provider business mailing address

497 1ST ST
PORT CARBON PA
17965-1623
US

V. Phone/Fax

Practice location:
  • Phone: 570-449-8760
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOP001874L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: