Provider Demographics
NPI:1568172260
Name:WITTKOETTER, STEPHANIE (AGNP-C)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:WITTKOETTER
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 776084
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6084
Mailing Address - Country:US
Mailing Address - Phone:131-436-4758
Mailing Address - Fax:
Practice Address - Street 1:12445 DORSETT RD
Practice Address - Street 2:
Practice Address - City:MARYLAND HEIGHTS
Practice Address - State:MO
Practice Address - Zip Code:63043-3907
Practice Address - Country:US
Practice Address - Phone:314-343-4440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-05
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022038661363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care