Provider Demographics
NPI:1902158421
Name:THEISEN, MICAELA T (DNP, FNP-BC)
Entity Type:Individual
Prefix:
First Name:MICAELA
Middle Name:T
Last Name:THEISEN
Suffix:
Gender:F
Credentials:DNP, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:945 E 42ND AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99203-6201
Mailing Address - Country:US
Mailing Address - Phone:509-202-8109
Mailing Address - Fax:856-686-5218
Practice Address - Street 1:HWY 191 AND HOSPITAL DRIVE
Practice Address - Street 2:
Practice Address - City:CHINLE
Practice Address - State:AZ
Practice Address - Zip Code:86503
Practice Address - Country:US
Practice Address - Phone:928-674-7090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-08
Last Update Date:2024-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60577678207P00000X, 363L00000X, 363LF0000X
IDNP-1523A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2047222Medicaid