Provider Demographics
NPI:1750847448
Name:MIETELSKI, LISA (LPN)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:MIETELSKI
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 OFFICE CENTER DR
Mailing Address - Street 2:SUITE 400
Mailing Address - City:FORT WASHINGTON
Mailing Address - State:PA
Mailing Address - Zip Code:19034-3234
Mailing Address - Country:US
Mailing Address - Phone:267-513-1995
Mailing Address - Fax:267-513-1729
Practice Address - Street 1:500 OFFICE CENTER DR
Practice Address - Street 2:SUITE 400
Practice Address - City:FORT WASHINGTON
Practice Address - State:PA
Practice Address - Zip Code:19034-3234
Practice Address - Country:US
Practice Address - Phone:267-513-1995
Practice Address - Fax:267-513-1729
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-18
Last Update Date:2019-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPN308748164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse