Provider Demographics
NPI:1639317910
Name:O'NEILL, MIKALAH CAROL JANE (CNM,)
Entity Type:Individual
Prefix:
First Name:MIKALAH
Middle Name:CAROL JANE
Last Name:O'NEILL
Suffix:
Gender:F
Credentials:CNM,
Other - Prefix:
Other - First Name:CAROL
Other - Middle Name:JANE
Other - Last Name:O'NEILL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNM
Mailing Address - Street 1:1560 E MAPLE RD
Mailing Address - Street 2:SUITE 400-CREDENTIALING DEPARTMENT
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-1138
Mailing Address - Country:US
Mailing Address - Phone:313-745-4525
Mailing Address - Fax:313-745-4399
Practice Address - Street 1:4201 SAINT ANTOINE ST
Practice Address - Street 2:SUITE 4C
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2153
Practice Address - Country:US
Practice Address - Phone:313-745-4525
Practice Address - Fax:313-745-4399
Is Sole Proprietor?:No
Enumeration Date:2009-01-26
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704196544367A00000X
MITW053571207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIF27398Medicare UPIN
MI3133379Medicaid