Healthcare Provider Details

I. General information

NPI: 1881033785
Provider Name (Legal Business Name): SHIRLY MITTELMAN MDN, RN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2013
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15417 WAYNITA WAY NE
BOTHELL WA
98011-7442
US

IV. Provider business mailing address

15417 WAYNITA WAY NE
BOTHELL WA
98011-7442
US

V. Phone/Fax

Practice location:
  • Phone: 425-442-7012
  • Fax:
Mailing address:
  • Phone: 425-442-7012
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number60941412
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: