Healthcare Provider Details

I. General information

NPI: 1265701999
Provider Name (Legal Business Name): MARY JANE WITTER CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2011
Last Update Date: 12/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 HIGHLAND AVE SE SUITE 100
ROANOKE VA
24013-2201
US

IV. Provider business mailing address

21 HIGHLAND AVE SE SUITE 100
ROANOKE VA
24013-2201
US

V. Phone/Fax

Practice location:
  • Phone: 540-855-9177
  • Fax: 540-345-7559
Mailing address:
  • Phone: 540-855-9177
  • Fax: 540-345-7559

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0024074873
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: