Healthcare Provider Details

I. General information

NPI: 1942649009
Provider Name (Legal Business Name): SUSAN M WITTMAN RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2013
Last Update Date: 06/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1275 BELL AVE
HARTFORD WI
53027-1976
US

IV. Provider business mailing address

1583 BLUEBELL DR
HARTFORD WI
53027-8403
US

V. Phone/Fax

Practice location:
  • Phone: 262-673-7339
  • Fax:
Mailing address:
  • Phone: 262-397-8481
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number8686-40
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: