Provider Demographics
NPI:1588908883
Name:LITZAU, MIRANDA JOY
Entity type:Individual
Prefix:MRS
First Name:MIRANDA
Middle Name:JOY
Last Name:LITZAU
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 1:14499 195TH ST SE
Mailing Address - Street 2:
Mailing Address - City:LAKE LILLIAN
Mailing Address - State:MN
Mailing Address - Zip Code:56253-9567
Mailing Address - Country:US
Mailing Address - Phone:320-220-4333
Mailing Address - Fax:
Practice Address - Street 1:246 MAIN ST S
Practice Address - Street 2:
Practice Address - City:HUTCHINSON
Practice Address - State:MN
Practice Address - Zip Code:55350-2587
Practice Address - Country:US
Practice Address - Phone:320-587-5162
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-27
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNL640936164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse