Provider Demographics
NPI:1740787365
Name:MIKITISH, LINDA
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:
Last Name:MIKITISH
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 1:858 W QUARTER DR
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-2049
Mailing Address - Country:US
Mailing Address - Phone:208-602-5933
Mailing Address - Fax:208-706-7059
Practice Address - Street 1:858 W QUARTER DR
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-2049
Practice Address - Country:US
Practice Address - Phone:208-602-5933
Practice Address - Fax:208-706-7059
Is Sole Proprietor?:No
Enumeration Date:2018-04-10
Last Update Date:2018-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID38314163WC3500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC3500XNursing Service ProvidersRegistered NurseCardiac Rehabilitation