Provider Demographics
NPI:1225582364
Name:DEWITT, ROBIN
Entity Type:Individual
Prefix:
First Name:ROBIN
Middle Name:
Last Name:DEWITT
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 1:163 W FIRECLAY AVE
Mailing Address - Street 2:402
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-2688
Mailing Address - Country:US
Mailing Address - Phone:385-255-0334
Mailing Address - Fax:
Practice Address - Street 1:344 E 100 S
Practice Address - Street 2:301
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-1700
Practice Address - Country:US
Practice Address - Phone:801-322-4257
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-05
Last Update Date:2016-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT152810177172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker