Provider Demographics
NPI:1902250889
Name:MORTENSEN, MISTI
Entity Type:Individual
Prefix:
First Name:MISTI
Middle Name:
Last Name:MORTENSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26652 MUSE ROAD
Mailing Address - Street 2:
Mailing Address - City:MUSE
Mailing Address - State:OK
Mailing Address - Zip Code:74949
Mailing Address - Country:US
Mailing Address - Phone:435-790-2159
Mailing Address - Fax:
Practice Address - Street 1:26652 MUSE ROAD
Practice Address - Street 2:
Practice Address - City:MUSE
Practice Address - State:OK
Practice Address - Zip Code:74949
Practice Address - Country:US
Practice Address - Phone:435-790-2159
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-18
Last Update Date:2016-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT160303451172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver