Provider Demographics
NPI:1144577495
Name:WITZIG, NICOLE L
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:L
Last Name:WITZIG
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 1:622 EAGLE ROCK AVE
Mailing Address - Street 2:
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-2994
Mailing Address - Country:US
Mailing Address - Phone:973-669-0078
Mailing Address - Fax:973-669-1113
Practice Address - Street 1:2360 MORRIS AVE
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:NJ
Practice Address - Zip Code:07083-5707
Practice Address - Country:US
Practice Address - Phone:908-206-1700
Practice Address - Fax:908-206-1720
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-06
Last Update Date:2014-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01452000225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist