Provider Demographics
NPI:1093073934
Name:WITTWAY, KELLY JO
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:JO
Last Name:WITTWAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12049 BANDY RD
Mailing Address - Street 2:
Mailing Address - City:ALLIANCE
Mailing Address - State:OH
Mailing Address - Zip Code:44601-9212
Mailing Address - Country:US
Mailing Address - Phone:330-584-2150
Mailing Address - Fax:
Practice Address - Street 1:12049 BANDY RD
Practice Address - Street 2:
Practice Address - City:ALLIANCE
Practice Address - State:OH
Practice Address - Zip Code:44601-9212
Practice Address - Country:US
Practice Address - Phone:330-584-2150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-29
Last Update Date:2012-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH401189970111172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker