Provider Demographics
NPI:1528259140
Name:WITRAGO, SUSANNA
Entity type:Individual
Prefix:
First Name:SUSANNA
Middle Name:
Last Name:WITRAGO
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 1:1021 W LA CADENA DR
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92501-1413
Mailing Address - Country:US
Mailing Address - Phone:951-784-8010
Mailing Address - Fax:951-784-2859
Practice Address - Street 1:1021 W LA CADENA DR
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-1413
Practice Address - Country:US
Practice Address - Phone:951-784-8010
Practice Address - Fax:951-784-2859
Is Sole Proprietor?:No
Enumeration Date:2007-08-08
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN 197301164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse