Provider Demographics
NPI:1821661687
Name:PATTERSON, MIA LEA
Entity Type:Individual
Prefix:
First Name:MIA
Middle Name:LEA
Last Name:PATTERSON
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 1:102 BURNETT EXT
Mailing Address - Street 2:
Mailing Address - City:GALLIPOLIS
Mailing Address - State:OH
Mailing Address - Zip Code:45631-1988
Mailing Address - Country:US
Mailing Address - Phone:740-612-0399
Mailing Address - Fax:
Practice Address - Street 1:102 BURNETT EXT
Practice Address - Street 2:
Practice Address - City:GALLIPOLIS
Practice Address - State:OH
Practice Address - Zip Code:45631-1988
Practice Address - Country:US
Practice Address - Phone:740-612-0399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-20
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0409225Medicaid