Provider Demographics
NPI:1417931791
Name:KIETA, MICKI S (CRNA)
Entity Type:Individual
Prefix:MS
First Name:MICKI
Middle Name:S
Last Name:KIETA
Suffix:
Gender:F
Credentials:CRNA
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 60475
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70596-0475
Mailing Address - Country:US
Mailing Address - Phone:337-988-1890
Mailing Address - Fax:
Practice Address - Street 1:4212 W CONGRESS ST
Practice Address - Street 2:SUITE 3200
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70506-6765
Practice Address - Country:US
Practice Address - Phone:337-981-3546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP03115367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1695441Medicaid
LA1695441Medicaid