Provider Demographics
NPI:1265065296
Name:MISSIAEN, VI
Entity type:Individual
Prefix:
First Name:VI
Middle Name:
Last Name:MISSIAEN
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 1:1323 24TH ST APT 1
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50311-3143
Mailing Address - Country:US
Mailing Address - Phone:319-321-8629
Mailing Address - Fax:
Practice Address - Street 1:118 SE 9TH ST
Practice Address - Street 2:
Practice Address - City:PELLA
Practice Address - State:IA
Practice Address - Zip Code:50219-2200
Practice Address - Country:US
Practice Address - Phone:641-628-1280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-18
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA22980183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist