Provider Demographics
NPI:1619393204
Name:ITVELDT, FRED MICHAEL (MSN)
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:MICHAEL
Last Name:ITVELDT
Suffix:
Gender:M
Credentials:MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12615 E MISSION AVE STE 310
Mailing Address - Street 2:
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99216-1047
Mailing Address - Country:US
Mailing Address - Phone:509-707-8581
Mailing Address - Fax:509-443-5269
Practice Address - Street 1:12615 E MISSION AVE STE 310
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99216-1047
Practice Address - Country:US
Practice Address - Phone:509-707-8581
Practice Address - Fax:509-443-5269
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-06
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60451837363L00000X
WAAP 60451837363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner