Provider Demographics
NPI:1619441169
Name:MIKOVILJE, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:MIKOVILJE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4174 ROAD 550
Mailing Address - Street 2:
Mailing Address - City:KILN
Mailing Address - State:MS
Mailing Address - Zip Code:39556-8026
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2316 WALKER BUILDING
Practice Address - Street 2:
Practice Address - City:AUBURN UNIVERSITY
Practice Address - State:AL
Practice Address - Zip Code:36849-0001
Practice Address - Country:US
Practice Address - Phone:228-467-8561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-17
Last Update Date:2019-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS12405390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program