Provider Demographics
NPI:1508296401
Name:WYTOVICH, NANCY
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:WYTOVICH
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 1:497 1ST ST
Mailing Address - Street 2:
Mailing Address - City:PORT CARBON
Mailing Address - State:PA
Mailing Address - Zip Code:17965-1623
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:497 1ST ST
Practice Address - Street 2:
Practice Address - City:PORT CARBON
Practice Address - State:PA
Practice Address - Zip Code:17965-1623
Practice Address - Country:US
Practice Address - Phone:570-449-8760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-14
Last Update Date:2013-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOP001874L224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant