Provider Demographics
NPI:1144579608
Name:MICKELSON, REBECA (RN)
Entity Type:Individual
Prefix:MRS
First Name:REBECA
Middle Name:
Last Name:MICKELSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:BECKY
Other - Middle Name:
Other - Last Name:MICKELSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1555 EAST 15TH
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601
Mailing Address - Country:US
Mailing Address - Phone:307-267-0103
Mailing Address - Fax:
Practice Address - Street 1:1555 EAST 15TH
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601
Practice Address - Country:US
Practice Address - Phone:307-267-0103
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-30
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY28391163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse