Healthcare Provider Details

I. General information

NPI: 1215952890
Provider Name (Legal Business Name): ANN S WITTPENN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 10/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

353 BLAIR PARK RD
WILLISTON VT
05495-7530
US

IV. Provider business mailing address

353 BLAIR PARK ROAD
WILLISTON VT
05495
US

V. Phone/Fax

Practice location:
  • Phone: 802-847-1440
  • Fax:
Mailing address:
  • Phone: 802-847-1440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number42-0009238
License Number StateVT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1005386
Identifier TypeMEDICAID
Identifier StateVT
Identifier Issuer
# 2
IdentifierE01748232
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: