Provider Demographics
NPI:1053680991
Name:MICKELSON, ANNIE LEE (DC)
Entity Type:Individual
Prefix:DR
First Name:ANNIE
Middle Name:LEE
Last Name:MICKELSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:ANNIE
Other - Middle Name:LEE
Other - Last Name:WILDBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:9033 ROCKY LAKE CT
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34238-4007
Mailing Address - Country:US
Mailing Address - Phone:612-940-0827
Mailing Address - Fax:
Practice Address - Street 1:9033 ROCKY LAKE CT
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34238-4007
Practice Address - Country:US
Practice Address - Phone:612-940-0827
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-21
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4726-12111N00000X
MN5549111N00000X
FL14478111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1053680991Medicaid