Provider Demographics
NPI:1285034116
Name:MIKUSA, AMY M (CNP)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:M
Last Name:MIKUSA
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2971 GRAHAM RD
Mailing Address - Street 2:
Mailing Address - City:STOW
Mailing Address - State:OH
Mailing Address - Zip Code:44224-3619
Mailing Address - Country:US
Mailing Address - Phone:330-688-7981
Mailing Address - Fax:330-688-7469
Practice Address - Street 1:2971 GRAHAM RD
Practice Address - Street 2:
Practice Address - City:STOW
Practice Address - State:OH
Practice Address - Zip Code:44224-3619
Practice Address - Country:US
Practice Address - Phone:330-688-7981
Practice Address - Fax:330-688-7469
Is Sole Proprietor?:No
Enumeration Date:2014-08-28
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA. 16284-NP363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0109397Medicaid
OHH374021Medicare PIN