Provider Demographics
NPI:1942768296
Name:WITT, TINA ANNETTE
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:ANNETTE
Last Name:WITT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 E 2ND AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30161-3210
Mailing Address - Country:US
Mailing Address - Phone:706-509-3000
Mailing Address - Fax:
Practice Address - Street 1:330 TURNER MCCALL BLVD SW STE 206
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-5632
Practice Address - Country:US
Practice Address - Phone:706-509-6834
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-06
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN178792363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily