Healthcare Provider Details

I. General information

NPI: 1578742086
Provider Name (Legal Business Name): TINA R GWITT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2007
Last Update Date: 10/31/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5239 COUNTY RD S
LITTLE SUAMICO WI
54141-8804
US

IV. Provider business mailing address

5239 COUNTY RD S
LITTLE SUAMICO WI
54141-8804
US

V. Phone/Fax

Practice location:
  • Phone: 920-606-8004
  • Fax: 920-826-2766
Mailing address:
  • Phone: 920-606-8004
  • Fax: 920-826-2766

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number31129-031
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: