Provider Demographics
NPI:1164774261
Name:MICKNICK, THERESA (PAC)
Entity Type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:
Last Name:MICKNICK
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:MR
Other - First Name:THERESA
Other - Middle Name:
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PAC
Mailing Address - Street 1:217 BELL MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:JERMYN
Mailing Address - State:PA
Mailing Address - Zip Code:18433-3611
Mailing Address - Country:US
Mailing Address - Phone:570-254-4663
Mailing Address - Fax:
Practice Address - Street 1:165 FALLBROOK ST
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:PA
Practice Address - Zip Code:18433
Practice Address - Country:US
Practice Address - Phone:570-282-3151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-12
Last Update Date:2012-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA001651L363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical