Provider Demographics
NPI:1093544645
Name:WITMER, MARY (BSN)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:WITMER
Suffix:
Gender:F
Credentials:BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3033 MCDONALD AVE
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86401-4235
Mailing Address - Country:US
Mailing Address - Phone:928-753-5678
Mailing Address - Fax:
Practice Address - Street 1:3033 MCDONALD AVE
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86401-4235
Practice Address - Country:US
Practice Address - Phone:928-753-5678
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-31
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ247963163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool