Basic Information
| Provider Information | |||||||||
| NPI: | 1336550409 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HUTTON | ||||||||
| FirstName: | WICHITTREE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 N 7TH ST | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170465040 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 301 W PHILADELPHIA ST | ||||||||
| Address2: | |||||||||
| City: | YORK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 174012941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7178486116 | ||||||||
| FaxNumber: | 7178527580 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2014 | ||||||||
| LastUpdateDate: | 06/26/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | R199129 | MD | N | Nursing Service Providers | Registered Nurse | 363L00000X | SP019233 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 103548859 | 05 | PA | MEDICAID |