Provider Demographics
NPI:1154719623
Name:MENLO FAMILY MEDICINE, PC
Entity type:Organization
Organization Name:MENLO FAMILY MEDICINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WITT
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:706-857-8692
Mailing Address - Street 1:PO BOX 147
Mailing Address - Street 2:7TH AVE
Mailing Address - City:MENLO
Mailing Address - State:GA
Mailing Address - Zip Code:30731-0147
Mailing Address - Country:US
Mailing Address - Phone:706-862-1717
Mailing Address - Fax:706-862-1718
Practice Address - Street 1:2968 HWY 337
Practice Address - Street 2:
Practice Address - City:MENLO
Practice Address - State:GA
Practice Address - Zip Code:30731-0147
Practice Address - Country:US
Practice Address - Phone:706-862-1717
Practice Address - Fax:706-862-1718
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-06
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN045044363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty