Provider Demographics
NPI:1962497768
Name:SIEBERT, MITZI MARIE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:MITZI
Middle Name:MARIE
Last Name:SIEBERT
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7317 MARINDA WAY
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-4420
Mailing Address - Country:US
Mailing Address - Phone:801-942-0944
Mailing Address - Fax:801-942-0944
Practice Address - Street 1:1906 W 3600 S
Practice Address - Street 2:
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84119-4715
Practice Address - Country:US
Practice Address - Phone:801-973-9675
Practice Address - Fax:801-973-0379
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT208935-4405163WW0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WW0101XNursing Service ProvidersRegistered NurseWomen's Health Care, Ambulatory