Provider Demographics
NPI:1154965242
Name:WITT, MERCEDES DANIELLE
Entity type:Individual
Prefix:MRS
First Name:MERCEDES
Middle Name:DANIELLE
Last Name:WITT
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 1:2512 JARRELL RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-8343
Mailing Address - Country:US
Mailing Address - Phone:615-332-4689
Mailing Address - Fax:
Practice Address - Street 1:1763 MADISON ST
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-4990
Practice Address - Country:US
Practice Address - Phone:931-278-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-31
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4401363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program