Provider Demographics
NPI:1073584777
Name:MITZEN, KELLY (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:
Last Name:MITZEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:DILORENZO TRICARE HEALTH CLINIC
Mailing Address - Street 2:ARMY PENTAGON 5801
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20310-2802
Mailing Address - Country:US
Mailing Address - Phone:703-692-8950
Mailing Address - Fax:
Practice Address - Street 1:DILORENZO TRICARE HEALTH CLINIC
Practice Address - Street 2:ARMY PENTAGON 5801
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20310-2802
Practice Address - Country:US
Practice Address - Phone:703-692-8950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2014-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002992363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
1073584777OtherNPI