Provider Demographics
NPI:1629456421
Name:MUTTEN, MESHACK
Entity Type:Individual
Prefix:
First Name:MESHACK
Middle Name:
Last Name:MUTTEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4157 BEECHWOLD DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43224-1822
Mailing Address - Country:US
Mailing Address - Phone:717-538-3887
Mailing Address - Fax:
Practice Address - Street 1:4157 BEECHWOLD DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43224-1822
Practice Address - Country:US
Practice Address - Phone:717-538-3887
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-12
Last Update Date:2015-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH159063164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse