Provider Demographics
NPI:1821475245
Name:WITTE, MARY D (RN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:D
Last Name:WITTE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:649KENILWORTH AVE
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55803
Mailing Address - Country:US
Mailing Address - Phone:218-820-6506
Mailing Address - Fax:
Practice Address - Street 1:9436 SAINT MATHIAS RD
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401-5165
Practice Address - Country:US
Practice Address - Phone:218-855-1004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-06
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR-103555-3163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN129-RNMedicaid