Provider Demographics
NPI:1386024479
Name:WITZGALL, NAN MARY (PT)
Entity Type:Individual
Prefix:
First Name:NAN
Middle Name:MARY
Last Name:WITZGALL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:NAN
Other - Middle Name:MARY
Other - Last Name:BIESZKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:824 S ADELAIDE ST
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-2202
Mailing Address - Country:US
Mailing Address - Phone:810-845-4538
Mailing Address - Fax:
Practice Address - Street 1:1235 S CENTER RD
Practice Address - Street 2:UNIT 12
Practice Address - City:BURTON
Practice Address - State:MI
Practice Address - Zip Code:48509-1700
Practice Address - Country:US
Practice Address - Phone:810-743-8820
Practice Address - Fax:810-743-5908
Is Sole Proprietor?:No
Enumeration Date:2015-06-03
Last Update Date:2015-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501003078225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist