Provider Demographics
NPI:1205038007
Name:MIKKELSEN, NISSA
Entity Type:Individual
Prefix:MS
First Name:NISSA
Middle Name:
Last Name:MIKKELSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 N. HWY 89
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86313
Mailing Address - Country:US
Mailing Address - Phone:928-445-4860
Mailing Address - Fax:
Practice Address - Street 1:NORTHERN ARIZONA VA HCS
Practice Address - Street 2:500 N. HWY 89
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86313
Practice Address - Country:US
Practice Address - Phone:928-445-4860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5570124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist