Provider Demographics
NPI:1417000878
Name:WITTENBURG, REBECCA L (CNP)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:L
Last Name:WITTENBURG
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 OAK ST NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-4725
Mailing Address - Country:US
Mailing Address - Phone:505-855-5525
Mailing Address - Fax:505-884-4006
Practice Address - Street 1:300 OAK ST NE
Practice Address - Street 2:300
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-4725
Practice Address - Country:US
Practice Address - Phone:505-855-5525
Practice Address - Fax:505-884-4006
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2016-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR21445363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMA5384Medicaid
NM202015257OtherPRESBYTERIAN HEALTH
NMNM006F55OtherBCBS OF NM
NMS86702Medicare UPIN
NM345731701Medicare PIN