Provider Demographics
NPI:1164064945
Name:MICK, DENISE ALICIA (NP)
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:ALICIA
Last Name:MICK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:677 CHURCH ST WELLSTAR KENNESTONE HOSPITAL
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060
Mailing Address - Country:US
Mailing Address - Phone:678-923-8877
Mailing Address - Fax:
Practice Address - Street 1:677 CHURCH ST WELLSTAR KENNESTONE HOSPITAL
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060
Practice Address - Country:US
Practice Address - Phone:678-923-8877
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-12
Last Update Date:2022-07-15
Deactivation Date:2019-10-15
Deactivation Code:
Reactivation Date:2019-11-07
Provider Licenses
StateLicense IDTaxonomies
GARN152372163WN0800X
GANCO-000008363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163WN0800XNursing Service ProvidersRegistered NurseNeuroscience