Provider Demographics
NPI:1508296732
Name:MICKLEY, SUSAN (CPM)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:MICKLEY
Suffix:
Gender:F
Credentials:CPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4052 OLEATHA AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63116-3606
Mailing Address - Country:US
Mailing Address - Phone:314-452-9291
Mailing Address - Fax:
Practice Address - Street 1:4052 OLEATHA AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63116-3606
Practice Address - Country:US
Practice Address - Phone:314-452-9291
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-25
Last Update Date:2013-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO13100027176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife