Healthcare Provider Details

I. General information

NPI: 1790574358
Provider Name (Legal Business Name): MIKETTA DERELLE STEWART LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2025
Last Update Date: 05/01/2025
Certification Date: 04/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1555 MEADOWVIEW DRIVE SUITED 5 & 6
DANVILLE VA
24541
US

IV. Provider business mailing address

422 JOHN ST
EDEN NC
27288-2879
US

V. Phone/Fax

Practice location:
  • Phone: 877-848-9810
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number91518
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: