Provider Demographics
NPI:1700056207
Name:WITTKE, LAURA R (MS RD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:R
Last Name:WITTKE
Suffix:
Gender:F
Credentials:MS RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:809 W RIORDAN RD
Mailing Address - Street 2:SUTIE 100 #327
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-0801
Mailing Address - Country:US
Mailing Address - Phone:928-814-9585
Mailing Address - Fax:
Practice Address - Street 1:809 W RIORDAN RD
Practice Address - Street 2:SUTIE 100 #327
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-0801
Practice Address - Country:US
Practice Address - Phone:928-814-9585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-11
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ625808133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered