Provider Demographics
NPI:1073868519
Name:WITTENBROOK, KELLY ANN (ANP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:WITTENBROOK
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5716 ROUTE 380
Mailing Address - Street 2:
Mailing Address - City:SINCLAIRVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14782-9657
Mailing Address - Country:US
Mailing Address - Phone:716-444-7551
Mailing Address - Fax:716-338-1575
Practice Address - Street 1:20 W FAIRMOUNT AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NY
Practice Address - Zip Code:14750
Practice Address - Country:US
Practice Address - Phone:716-338-0033
Practice Address - Fax:716-338-1575
Is Sole Proprietor?:No
Enumeration Date:2012-07-20
Last Update Date:2018-05-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY306145363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01406284Medicaid