Provider Demographics
NPI:1699850446
Name:MIKKALSON, GENELL LYNN (CNM)
Entity Type:Individual
Prefix:MS
First Name:GENELL
Middle Name:LYNN
Last Name:MIKKALSON
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:234 ROXBURY RD
Mailing Address - Street 2:
Mailing Address - City:MARLBOROUGH
Mailing Address - State:NH
Mailing Address - Zip Code:03455-2216
Mailing Address - Country:US
Mailing Address - Phone:603-876-9448
Mailing Address - Fax:
Practice Address - Street 1:580 COURT ST
Practice Address - Street 2:
Practice Address - City:KEENE
Practice Address - State:NH
Practice Address - Zip Code:03431-1718
Practice Address - Country:US
Practice Address - Phone:603-354-5454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH048845-23-01367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH048845-23-01OtherARNP-CERTIFIED NURSE MIDW
NH048845-21OtherREGISTERED NURSE