Provider Demographics
NPI:1164100079
Name:WITCHER, HEIDI JENELLE
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:JENELLE
Last Name:WITCHER
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 1:27115 SUNSET PINES DR.
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77373
Mailing Address - Country:US
Mailing Address - Phone:197-959-9619
Mailing Address - Fax:
Practice Address - Street 1:2021 RAYFORD RD
Practice Address - Street 2:104
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77386-7928
Practice Address - Country:US
Practice Address - Phone:404-955-2115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-10
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX17467771744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management