Healthcare Provider Details

I. General information

NPI: 1902250889
Provider Name (Legal Business Name): MISTI MORTENSEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2016
Last Update Date: 04/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26652 MUSE ROAD
MUSE OK
74949
US

IV. Provider business mailing address

26652 MUSE ROAD
MUSE OK
74949
US

V. Phone/Fax

Practice location:
  • Phone: 435-790-2159
  • Fax:
Mailing address:
  • Phone: 435-790-2159
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number160303451
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: