Provider Demographics
NPI:1962743815
Name:MITIC, IVANA (CRNA)
Entity type:Individual
Prefix:
First Name:IVANA
Middle Name:
Last Name:MITIC
Suffix:
Gender:
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 RIDGEBROOK RD STE 202
Mailing Address - Street 2:
Mailing Address - City:SPARKS
Mailing Address - State:MD
Mailing Address - Zip Code:21152-9476
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:909 RIDGEBROOK RD STE 202
Practice Address - Street 2:
Practice Address - City:SPARKS
Practice Address - State:MD
Practice Address - Zip Code:21152-9476
Practice Address - Country:US
Practice Address - Phone:410-870-5482
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-01
Last Update Date:2025-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX784417163W00000X
MDR212937363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse