Provider Demographics
NPI:1063011773
Name:MITTLEIDER, GAYLENE
Entity Type:Individual
Prefix:
First Name:GAYLENE
Middle Name:
Last Name:MITTLEIDER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 4TH ST S
Mailing Address - Street 2:
Mailing Address - City:CARRINGTON
Mailing Address - State:ND
Mailing Address - Zip Code:58421-1967
Mailing Address - Country:US
Mailing Address - Phone:170-165-2135
Mailing Address - Fax:
Practice Address - Street 1:1025 4TH ST S
Practice Address - Street 2:
Practice Address - City:CARRINGTON
Practice Address - State:ND
Practice Address - Zip Code:58421-1967
Practice Address - Country:US
Practice Address - Phone:701-652-1354
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-22
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant