Provider Demographics
NPI:1033467675
Name:DEETJEN, MIREILLE (LPN)
Entity Type:Individual
Prefix:
First Name:MIREILLE
Middle Name:
Last Name:DEETJEN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 E 60TH ST
Mailing Address - Street 2:APT 9C
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10022-1604
Mailing Address - Country:US
Mailing Address - Phone:917-862-5215
Mailing Address - Fax:718-347-4643
Practice Address - Street 1:250 E 60TH ST
Practice Address - Street 2:APT 9C
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10022-1604
Practice Address - Country:US
Practice Address - Phone:917-862-5215
Practice Address - Fax:718-347-4643
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-29
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY165663164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse