Healthcare Provider Details

I. General information

NPI: 1366232928
Provider Name (Legal Business Name): MADELYNN C WITTEMANN MAT, LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2025
Last Update Date: 07/29/2025
Certification Date: 07/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1840 S 1300 E
SALT LAKE CITY UT
84105-3617
US

IV. Provider business mailing address

2727 S 625 W APT B201
BOUNTIFUL UT
84010-8272
US

V. Phone/Fax

Practice location:
  • Phone: 801-832-2200
  • Fax:
Mailing address:
  • Phone: 480-494-7487
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number14220405-4810
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: