Provider Demographics
NPI:1992785604
Name:MITZAK, ANNE MERCITA (CRNA)
Entity type:Individual
Prefix:MISS
First Name:ANNE
Middle Name:MERCITA
Last Name:MITZAK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4710 39TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-8225
Mailing Address - Country:US
Mailing Address - Phone:360-923-9555
Mailing Address - Fax:
Practice Address - Street 1:MAMC
Practice Address - Street 2:BLDG 9040 FITZSIMMONS DRIVE
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98431-0001
Practice Address - Country:US
Practice Address - Phone:253-968-1975
Practice Address - Fax:253-968-3738
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD054106367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAVAD000Medicare UPIN