Provider Demographics
NPI:1689674988
Name:WITTE, COLLEEN MARIE (RN MS ANP)
Entity Type:Individual
Prefix:MS
First Name:COLLEEN
Middle Name:MARIE
Last Name:WITTE
Suffix:
Gender:F
Credentials:RN MS ANP
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:MARIE
Other - Last Name:BALES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1247 ROSITA RD
Mailing Address - Street 2:
Mailing Address - City:PACIFICA
Mailing Address - State:CA
Mailing Address - Zip Code:94044-4224
Mailing Address - Country:US
Mailing Address - Phone:650-355-1912
Mailing Address - Fax:
Practice Address - Street 1:1001 POTRERO AVE
Practice Address - Street 2:BLDG. 9, ROOM 115
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110-3518
Practice Address - Country:US
Practice Address - Phone:415-206-2649
Practice Address - Fax:415-206-6073
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2015-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARNP421777363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6124OtherNP CERTIFICATE