Provider Demographics
NPI:1942592076
Name:WITTICH, DOLORES TERESA (RN)
Entity Type:Individual
Prefix:
First Name:DOLORES
Middle Name:TERESA
Last Name:WITTICH
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 1:80 BAUER AVE
Mailing Address - Street 2:
Mailing Address - City:MANORVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11949-2502
Mailing Address - Country:US
Mailing Address - Phone:631-334-9907
Mailing Address - Fax:
Practice Address - Street 1:80 BAUER AVE
Practice Address - Street 2:
Practice Address - City:MANORVILLE
Practice Address - State:NY
Practice Address - Zip Code:11949-2502
Practice Address - Country:US
Practice Address - Phone:631-334-9907
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-09
Last Update Date:2011-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY22281158163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse