Provider Demographics
NPI:1073078853
Name:MIYAMOTO, ANNETTE A (LPN)
Entity type:Individual
Prefix:
First Name:ANNETTE
Middle Name:A
Last Name:MIYAMOTO
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1321 E POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:DEMING
Mailing Address - State:NM
Mailing Address - Zip Code:88030-4807
Mailing Address - Country:US
Mailing Address - Phone:575-546-5951
Mailing Address - Fax:575-546-5994
Practice Address - Street 1:180 N DATE ST
Practice Address - Street 2:
Practice Address - City:T OR C
Practice Address - State:NM
Practice Address - Zip Code:87901-2810
Practice Address - Country:US
Practice Address - Phone:575-894-8372
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-05
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NML15727164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse