Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LG0600X | Nurse Practitioner - Gerontology | SP022939 | PA |
NPI | 1023697000 |
---|---|
Provider Name | Tamika Mickie |
First Address | Drexel Hill, PA 19026-3009 |
Second Address | Horsham, PA 19044-2223 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 06/04/2021 |
Last Update Date | 23/04/2021 |