Basic Information
| Provider Information | |||||||||
| NPI: | 1689292948 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WITT | ||||||||
| FirstName: | MADISON | ||||||||
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| Mailing Information | |||||||||
| Address1: | 252 CHEROKEE PROFESSIONAL PARK | ||||||||
| Address2: | |||||||||
| City: | MARYVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378045153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8659805200 | ||||||||
| FaxNumber: | 8659805201 | ||||||||
| Practice Location | |||||||||
| Address1: | 252 CHEROKEE PROFESSIONAL PARK | ||||||||
| Address2: | |||||||||
| City: | MARYVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378045153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8659805200 | ||||||||
| FaxNumber: | 8659805201 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2020 | ||||||||
| LastUpdateDate: | 10/17/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 229806 | TN | N | Nursing Service Providers | Registered Nurse | 363LF0000X | 29706 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | Q068076 | 05 | TN | MEDICAID |