Provider Demographics
NPI:1790015527
Name:MITKOS, SANDRA LEE (FNP)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:LEE
Last Name:MITKOS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 HEALTH WAY DR
Mailing Address - Street 2:
Mailing Address - City:POTOSI
Mailing Address - State:MO
Mailing Address - Zip Code:63664-1420
Mailing Address - Country:US
Mailing Address - Phone:573-438-5451
Mailing Address - Fax:573-438-2399
Practice Address - Street 1:108 FRIZZELL ST
Practice Address - Street 2:
Practice Address - City:POTOSI
Practice Address - State:MO
Practice Address - Zip Code:63664-1505
Practice Address - Country:US
Practice Address - Phone:573-438-5408
Practice Address - Fax:573-438-2419
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-29
Last Update Date:2018-04-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2009036279363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily