Provider Demographics
NPI:1538880588
Name:ZETTER, MIA JEANETTE
Entity type:Individual
Prefix:
First Name:MIA
Middle Name:JEANETTE
Last Name:ZETTER
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 1:3409 MILAM LN APT 329
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40502-3630
Mailing Address - Country:US
Mailing Address - Phone:503-860-7816
Mailing Address - Fax:
Practice Address - Street 1:104 LEGACY DR
Practice Address - Street 2:
Practice Address - City:BEREA
Practice Address - State:KY
Practice Address - Zip Code:40403-9594
Practice Address - Country:US
Practice Address - Phone:859-986-2323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-08
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3018051363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily