MEDICARE: MS. ELIZABETH ANN MITTELSTAEDT

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	163W00000X	Registered Nurse	RN00101072	WA

General Provider Information

NPI Number	:	1033191192
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ELIZABETH ANN MITTELSTAEDT

Provider Business Mailing Address
First Line	:	1060 GAFFNEY RD
Second Line	:	COMMANDER, USA-MEDDAC-AK, ATTN: MCUC-MMD-QM
City	:	FORT WAINWRIGHT
State	:	AK
Zip	:	99703-5001
Country	:	US
Telephone Number	:	907-353-5418
Fax Number	:	907-353-4845

Provider Business Practice Location Address
First Line	:	1060 GAFFNEY RD
Second Line	:	COMMANDER, USA-MEDDAC-AK, ATTN: MCUC-MMD-QM
City	:	FORT WAINWRIGHT
State	:	AK
Zip	:	99703-5001
Country	:	US
Telephone Number	:	907-353-5418
Fax Number	:	907-353-4845

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

Provider Enumeration Date	:	11/15/2005
Last Update Date	:	07/08/2007

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