Provider Demographics
NPI:1306390257
Name:MISA, IANETA
Entity Type:Individual
Prefix:
First Name:IANETA
Middle Name:
Last Name:MISA
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 1:688 MORTON DRIVE
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE
Mailing Address - State:UTAH
Mailing Address - Zip Code:84116
Mailing Address - Country:UM
Mailing Address - Phone:801-325-1428
Mailing Address - Fax:
Practice Address - Street 1:344 E 100 S
Practice Address - Street 2:SUITE 301
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-1700
Practice Address - Country:US
Practice Address - Phone:801-322-4257
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-09
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker