Provider Demographics
NPI:1942649009
Name:WITTMAN, SUSAN M (RPH)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:M
Last Name:WITTMAN
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1583 BLUEBELL DR
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:WI
Mailing Address - Zip Code:53027-8403
Mailing Address - Country:US
Mailing Address - Phone:262-397-8481
Mailing Address - Fax:
Practice Address - Street 1:1275 BELL AVE
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:WI
Practice Address - Zip Code:53027-1976
Practice Address - Country:US
Practice Address - Phone:262-673-7339
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-21
Last Update Date:2013-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8686-40261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health