Provider Demographics
NPI:1316563604
Name:WITTNEBERT, MARY TERESA (DNP, ARNP, FNP-BC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:TERESA
Last Name:WITTNEBERT
Suffix:
Gender:F
Credentials:DNP, ARNP, FNP-BC
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:TERESA
Other - Last Name:VOELKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:29 BLOCKHOUSE CT
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-3020
Mailing Address - Country:US
Mailing Address - Phone:386-846-4188
Mailing Address - Fax:
Practice Address - Street 1:305 MEMORIAL MEDICAL PKWY STE 301
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-5157
Practice Address - Country:US
Practice Address - Phone:386-231-1350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-22
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11007706363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily