Provider Demographics
NPI:1245600063
Name:MISTRETTA, DEANNA L (LPN)
Entity Type:Individual
Prefix:
First Name:DEANNA
Middle Name:L
Last Name:MISTRETTA
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 1:4740 W BUTTERFIELD HWY APT 3
Mailing Address - Street 2:
Mailing Address - City:OLIVET
Mailing Address - State:MI
Mailing Address - Zip Code:49076-9416
Mailing Address - Country:US
Mailing Address - Phone:610-657-9323
Mailing Address - Fax:
Practice Address - Street 1:4740 W BUTTERFIELD HWY APT 3
Practice Address - Street 2:
Practice Address - City:OLIVET
Practice Address - State:MI
Practice Address - Zip Code:49076-9416
Practice Address - Country:US
Practice Address - Phone:610-657-9323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-06
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703115548164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse