Provider Demographics
NPI:1902804297
Name:WITT, CONNIE LOUISE (FNP-C)
Entity Type:Individual
Prefix:MS
First Name:CONNIE
Middle Name:LOUISE
Last Name:WITT
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 12938
Mailing Address - Street 2:C/O CLINIC MANAGEMENT
Mailing Address - City:CALHOUN
Mailing Address - State:GA
Mailing Address - Zip Code:30703
Mailing Address - Country:US
Mailing Address - Phone:706-602-7800
Mailing Address - Fax:
Practice Address - Street 1:160 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:TRION
Practice Address - State:GA
Practice Address - Zip Code:30753-1125
Practice Address - Country:US
Practice Address - Phone:706-734-7302
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN045044363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000973739DMedicaid
GA000973739HMedicaid
GA511I500804Medicare PIN