Provider Demographics
NPI:1629023031
Name:FIDDELKE, MISTI D (MPT)
Entity Type:Individual
Prefix:
First Name:MISTI
Middle Name:D
Last Name:FIDDELKE
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:RAVENNA
Mailing Address - State:NE
Mailing Address - Zip Code:68869-1321
Mailing Address - Country:US
Mailing Address - Phone:308-452-7154
Mailing Address - Fax:308-452-3394
Practice Address - Street 1:321 GRAND AVE
Practice Address - Street 2:
Practice Address - City:RAVENNA
Practice Address - State:NE
Practice Address - Zip Code:68869-1321
Practice Address - Country:US
Practice Address - Phone:308-452-7154
Practice Address - Fax:308-452-3394
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1761225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE470769316Medicaid
NE39601OtherBLUE CROSS BLUE SHIELD
NE650024438OtherRAILROAD MEDICARE