Provider Demographics
NPI:1881717262
Name:DEWITT, WENELLE R (LPTA)
Entity type:Individual
Prefix:
First Name:WENELLE
Middle Name:R
Last Name:DEWITT
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 OZARK ACRES DR
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-6361
Mailing Address - Country:US
Mailing Address - Phone:479-531-7022
Mailing Address - Fax:
Practice Address - Street 1:500 TIGER BOULEVARD
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-6361
Practice Address - Country:US
Practice Address - Phone:479-531-7022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1610225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant