Provider Demographics
NPI:1467753228
Name:MICKELSEN, VICKI LYNN (REGISTERED NURSE)
Entity Type:Individual
Prefix:MRS
First Name:VICKI
Middle Name:LYNN
Last Name:MICKELSEN
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5200 FAIRVIEW BLVD
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MN
Mailing Address - Zip Code:55092-8013
Mailing Address - Country:US
Mailing Address - Phone:651-982-7237
Mailing Address - Fax:651-982-7236
Practice Address - Street 1:5200 FAIRVIEW BLVD
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MN
Practice Address - Zip Code:55092-8013
Practice Address - Country:US
Practice Address - Phone:651-982-7237
Practice Address - Fax:651-982-7236
Is Sole Proprietor?:No
Enumeration Date:2010-11-10
Last Update Date:2010-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR073057-4163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse