Provider Demographics
NPI:1104027861
Name:MICKELSON, ASHLEE DIANE (MD)
Entity Type:Individual
Prefix:
First Name:ASHLEE
Middle Name:DIANE
Last Name:MICKELSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 N IRON BRIDGE WAY
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99202-4932
Mailing Address - Country:US
Mailing Address - Phone:509-444-8888
Mailing Address - Fax:509-444-7806
Practice Address - Street 1:3919 N MAPLE ST
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99205-1349
Practice Address - Country:US
Practice Address - Phone:509-444-8888
Practice Address - Fax:509-444-7806
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-30
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60458815208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics