Provider Demographics
NPI:1023364452
Name:MICKLEY, DEBORAH ELAINE
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:ELAINE
Last Name:MICKLEY
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 1:2828 CHICAGO AVE SOUTH
Mailing Address - Street 2:SUITE 300
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407
Mailing Address - Country:US
Mailing Address - Phone:612-859-1656
Mailing Address - Fax:
Practice Address - Street 1:2828 CHICAGO AVE SOUTH
Practice Address - Street 2:SUITE 300
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407
Practice Address - Country:US
Practice Address - Phone:612-859-1656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-03
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR1697085163W00000X
MN0661367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse