Provider Demographics
NPI:1992989339
Name:MITZEL, LAUREL A (LMP)
Entity type:Individual
Prefix:
First Name:LAUREL
Middle Name:A
Last Name:MITZEL
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2130
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98083-2130
Mailing Address - Country:US
Mailing Address - Phone:425-890-4421
Mailing Address - Fax:425-216-7283
Practice Address - Street 1:625 4TH AVE
Practice Address - Street 2:SUITE 303
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98033-9028
Practice Address - Country:US
Practice Address - Phone:425-890-4421
Practice Address - Fax:425-216-7283
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-20
Last Update Date:2007-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00008794174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMI5423OtherREGENCE BLUE SHIELD