Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 152W00000X | Optometrist | 4901003786 | MI |
N | 152WC0802X | Optomitrist - Corneal and Contact Lenses | 4901003786 | MI |
N | 152WP0200X | Pediatric Optomitrist | 4901003786 | MI |
NPI | 1366430068 |
---|---|
Provider Name | Kristina Nicole Wittrock |
First Address | Troy, MI 48084-3243 |
Second Address | Troy, MI 48084-3243 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/10/2005 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
KW003876 | BCBSM PIN (01) | MI |
U58232 | (02) | MI |