Provider Demographics
NPI:1265701999
Name:WITTER, MARY JANE (CPNP)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:JANE
Last Name:WITTER
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:21 HIGHLAND AVE SE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24013-2201
Mailing Address - Country:US
Mailing Address - Phone:540-855-9177
Mailing Address - Fax:540-345-7559
Practice Address - Street 1:21 HIGHLAND AVE SE
Practice Address - Street 2:SUITE 100
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24013-2201
Practice Address - Country:US
Practice Address - Phone:540-855-9177
Practice Address - Fax:540-345-7559
Is Sole Proprietor?:No
Enumeration Date:2011-12-27
Last Update Date:2011-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024074873208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1649362351OtherGROUP NPI