Provider Demographics
NPI:1962664136
Name:WITTENBERG BRAVARD, JUDY B (CNP)
Entity Type:Individual
Prefix:
First Name:JUDY
Middle Name:B
Last Name:WITTENBERG BRAVARD
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:843 MICHELTORENA ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90026-2701
Mailing Address - Country:US
Mailing Address - Phone:323-664-7971
Mailing Address - Fax:
Practice Address - Street 1:11101 VENICE BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90034-6914
Practice Address - Country:US
Practice Address - Phone:310-840-5755
Practice Address - Fax:310-218-5484
Is Sole Proprietor?:No
Enumeration Date:2008-06-30
Last Update Date:2012-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAS292576363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health