Provider Demographics
NPI:1548995350
Name:WITBRO, DANIELLE R (NDTR, CWP)
Entity type:Individual
Prefix:MRS
First Name:DANIELLE
Middle Name:R
Last Name:WITBRO
Suffix:
Gender:F
Credentials:NDTR, CWP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2216 GLENDALE AVE
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54303-6510
Mailing Address - Country:US
Mailing Address - Phone:920-427-9163
Mailing Address - Fax:
Practice Address - Street 1:737 CORMIER RD
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-4825
Practice Address - Country:US
Practice Address - Phone:920-405-1478
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-18
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI86052280136A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes136A00000XDietary & Nutritional Service ProvidersDietetic Technician, Registered