Provider Demographics
NPI:1700109980
Name:WITTER, BEVERLY SONIA
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:SONIA
Last Name:WITTER
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 1:350 LENOX RD
Mailing Address - Street 2:APT.1E
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11226-2276
Mailing Address - Country:US
Mailing Address - Phone:347-385-3537
Mailing Address - Fax:
Practice Address - Street 1:350 LENOX RD
Practice Address - Street 2:APT.1E
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11226-2276
Practice Address - Country:US
Practice Address - Phone:347-385-3537
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-02
Last Update Date:2010-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY451216163W00000X
NY219778-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No163W00000XNursing Service ProvidersRegistered Nurse