Provider Demographics
NPI:1629312798
Name:MIKITIUK, NATASHA
Entity Type:Individual
Prefix:
First Name:NATASHA
Middle Name:
Last Name:MIKITIUK
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 1:6805 FIVE STAR BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:ROCKLIN
Mailing Address - State:CA
Mailing Address - Zip Code:95677-4135
Mailing Address - Country:US
Mailing Address - Phone:916-624-4959
Mailing Address - Fax:916-624-3351
Practice Address - Street 1:6805 FIVE STAR BLVD STE 100
Practice Address - Street 2:
Practice Address - City:ROCKLIN
Practice Address - State:CA
Practice Address - Zip Code:95677-4135
Practice Address - Country:US
Practice Address - Phone:916-624-4959
Practice Address - Fax:916-624-3351
Is Sole Proprietor?:No
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist