MEDICARE: TIFFANY R WITTE APRN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	71011504A	IN

General Provider Information

NPI Number	:	1598435521
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIFFANY R WITTE APRN

Provider Business Mailing Address
First Line	:	215 STRATTON WAY
Second Line	:
City	:	DECATUR
State	:	IN
Zip	:	46733-1717
Country	:	US
Telephone Number	:	260-701-8433
Fax Number	:

Provider Business Practice Location Address
First Line	:	6017 STONEY CREEK DR
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-4410
Country	:	US
Telephone Number	:	260-267-5159
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/21/2021
Last Update Date	:	09/21/2021

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