Provider Demographics
NPI:1467151704
Name:MITTAN, DEMICE (LPN)
Entity Type:Individual
Prefix:
First Name:DEMICE
Middle Name:
Last Name:MITTAN
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 1:10021 16TH AVE E
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98445-3941
Mailing Address - Country:US
Mailing Address - Phone:253-720-7609
Mailing Address - Fax:
Practice Address - Street 1:3320 AUBURN WAY N
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98002-1805
Practice Address - Country:US
Practice Address - Phone:253-999-5723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-27
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALP60012429164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse