Provider Demographics
NPI:1154626232
Name:PALMER, MISTI D (LPT)
Entity type:Individual
Prefix:
First Name:MISTI
Middle Name:D
Last Name:PALMER
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11305 BELLEGRAVE AVE
Mailing Address - Street 2:
Mailing Address - City:MIRA LOMA
Mailing Address - State:CA
Mailing Address - Zip Code:91752-1602
Mailing Address - Country:US
Mailing Address - Phone:909-263-9716
Mailing Address - Fax:
Practice Address - Street 1:9047 ARROW RTE
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-4449
Practice Address - Country:US
Practice Address - Phone:909-466-8696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-20
Last Update Date:2011-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 35030167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT 35030OtherBOARD OF VOCATIONAL NURSES AND PSYCHIATRIC TECHNICIANS