MEDICARE: JENNIFER RAE WITT CPNP

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	363LP0200X	Pediatric Nurse Practitioner	APRN11008019	FL
2	363LP0200X	Pediatric Nurse Practitioner	0050-1620	NC
3	363L00000X	Nurse Practitioner	5001620	NC
4	363LP0200X	Pediatric Nurse Practitioner	203964	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1629190731
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER RAE WITT CPNP

Provider Business Mailing Address
First Line	:	150 SW CHAMBER CT STE 101
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34986-3413
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	150 SW CHAMBER CT STE 101
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34986-3413
Country	:	US
Telephone Number	:	772-301-0123
Fax Number	:	772-301-0124

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

Provider Enumeration Date	:	04/06/2007
Last Update Date	:	11/07/2023

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