Provider Demographics
NPI:1619115540
Name:YOUNG, MICKEY JEAN (RN)
Entity Type:Individual
Prefix:MRS
First Name:MICKEY
Middle Name:JEAN
Last Name:YOUNG
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1036 SHEFFIELD PL
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-7574
Mailing Address - Country:US
Mailing Address - Phone:618-466-1407
Mailing Address - Fax:
Practice Address - Street 1:1036 SHEFFIELD PL
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-7574
Practice Address - Country:US
Practice Address - Phone:618-567-1104
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-30
Last Update Date:2009-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO092255163WE0900X
IL041185157163WE0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WE0900XNursing Service ProvidersRegistered NurseEnterostomal Therapy