Provider Demographics
NPI:1073868519
Name:WITTENBROOK, KELLY ANN (ANP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:WITTENBROOK
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3155 GUINEA CIR
Mailing Address - Street 2:
Mailing Address - City:HAYES
Mailing Address - State:VA
Mailing Address - Zip Code:23072-4220
Mailing Address - Country:US
Mailing Address - Phone:716-397-9492
Mailing Address - Fax:716-338-1575
Practice Address - Street 1:3000 COLISEUM DR FL 2
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-5963
Practice Address - Country:US
Practice Address - Phone:757-736-1347
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-20
Last Update Date:2025-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.0037515363LA2200X
NY306145363LA2200X
SCAPN.29631363LA2200X
VA0024172480363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01406284Medicaid