Provider Demographics
NPI:1164731790
Name:MIKULS, MICHELLE LYNN (PT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LYNN
Last Name:MIKULS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2309 N 147TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68116-5129
Mailing Address - Country:US
Mailing Address - Phone:402-932-2522
Mailing Address - Fax:
Practice Address - Street 1:11912 ELM ST
Practice Address - Street 2:SUITE 106
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144-4443
Practice Address - Country:US
Practice Address - Phone:402-630-9756
Practice Address - Fax:402-504-3535
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-30
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NENE1250225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist