Provider Demographics
NPI:1790574358
Name:STEWART, MIKETTA DERELLE (LPN)
Entity type:Individual
Prefix:
First Name:MIKETTA
Middle Name:DERELLE
Last Name:STEWART
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 1:422 JOHN ST
Mailing Address - Street 2:
Mailing Address - City:EDEN
Mailing Address - State:NC
Mailing Address - Zip Code:27288-2879
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1555 MEADOWVIEW DRIVE
Practice Address - Street 2:SUITED 5 & 6
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24541
Practice Address - Country:US
Practice Address - Phone:877-848-9810
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-01
Last Update Date:2025-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC91518164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse