MEDICARE: LAUREL A MITZEL LMP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	MA00008794	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MI5423	OTHER	WA	REGENCE BLUE SHIELD

General Provider Information

NPI Number	:	1992989339
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAUREL A MITZEL LMP

Provider Business Mailing Address
First Line	:	PO BOX 2130
Second Line	:
City	:	KIRKLAND
State	:	WA
Zip	:	98083-2130
Country	:	US
Telephone Number	:	425-890-4421
Fax Number	:	425-216-7283

Provider Business Practice Location Address
First Line	:	625 4TH AVE
Second Line	:	SUITE 303
City	:	KIRKLAND
State	:	WA
Zip	:	98033-9028
Country	:	US
Telephone Number	:	425-890-4421
Fax Number	:	425-216-7283

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/20/2007
Last Update Date	:	12/20/2007

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Directions to “ LAUREL A MITZEL LMP” Practice Location

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