Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LF0000X | Nurse Practitioner - Family Medicine | A115535 | IA |
NPI | 1003224585 |
---|---|
Provider Name | Stephanie Witherow |
First Address | Davenport, IA 52801-1014 |
Second Address | Davenport, IA 52801-1014 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/07/2014 |
Last Update Date | 06/02/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1932193224 | (05) | IA |