Provider Demographics
NPI:1245224898
Name:MITTELSTED, ROBERTA A (ARNP)
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:A
Last Name:MITTELSTED
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 W 1ST ST
Mailing Address - Street 2:P.O. BOX 148
Mailing Address - City:SUMNER
Mailing Address - State:IA
Mailing Address - Zip Code:50674-1203
Mailing Address - Country:US
Mailing Address - Phone:563-578-5375
Mailing Address - Fax:563-578-5437
Practice Address - Street 1:909 W 1ST ST
Practice Address - Street 2:
Practice Address - City:SUMNER
Practice Address - State:IA
Practice Address - Zip Code:50674-1203
Practice Address - Country:US
Practice Address - Phone:563-578-5375
Practice Address - Fax:563-578-5437
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2009-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA045501363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA48947OtherWELLMARK BCBS
I17909OtherMEDICARE PART B
IA0265751Medicaid
IA48947OtherWELLMARK BCBS