Provider Demographics
NPI:1942331236
Name:MITTIE, KATHRYN WYNN (MSN, FNP)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:WYNN
Last Name:MITTIE
Suffix:
Gender:F
Credentials:MSN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19650 ROAD 30 1/2
Mailing Address - Street 2:
Mailing Address - City:MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:93638
Mailing Address - Country:US
Mailing Address - Phone:559-662-1262
Mailing Address - Fax:
Practice Address - Street 1:1280 E ALMOND AVE
Practice Address - Street 2:
Practice Address - City:MADERA
Practice Address - State:CA
Practice Address - Zip Code:93637-5606
Practice Address - Country:US
Practice Address - Phone:559-673-9021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16512363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily