Provider Demographics
NPI:1114117926
Name:PELT, MIA ELIZABETH (RN, CNM)
Entity Type:Individual
Prefix:
First Name:MIA
Middle Name:ELIZABETH
Last Name:PELT
Suffix:
Gender:F
Credentials:RN, CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 25608
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84125-0608
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5350 TALLMAN AVE NW
Practice Address - Street 2:SUITE 420
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98107-5902
Practice Address - Country:US
Practice Address - Phone:206-781-6080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-27
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60093356367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife