Provider Demographics
NPI:1114285517
Name:WITTIG, MALLORY RENEE (FNP)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:RENEE
Last Name:WITTIG
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:METROPOLIS
Mailing Address - State:IL
Mailing Address - Zip Code:62960-2461
Mailing Address - Country:US
Mailing Address - Phone:618-524-2182
Mailing Address - Fax:618-524-2451
Practice Address - Street 1:12 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:METROPOLIS
Practice Address - State:IL
Practice Address - Zip Code:62960-2461
Practice Address - Country:US
Practice Address - Phone:618-524-2182
Practice Address - Fax:618-524-2451
Is Sole Proprietor?:No
Enumeration Date:2012-04-24
Last Update Date:2018-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209009469363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily