Provider Demographics
NPI:1235845181
Name:KAMMERER, MICKY (FNP-C)
Entity Type:Individual
Prefix:
First Name:MICKY
Middle Name:
Last Name:KAMMERER
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 S. HAM LANE STE M
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95242
Mailing Address - Country:US
Mailing Address - Phone:209-336-9339
Mailing Address - Fax:209-224-5921
Practice Address - Street 1:777 S. HAM LANE STE M
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242
Practice Address - Country:US
Practice Address - Phone:209-336-9339
Practice Address - Fax:209-224-5921
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-24
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95024009363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner