Provider Demographics
NPI:1710370150
Name:MICKLES, VANESSA LYNETTE (PHARMD)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:LYNETTE
Last Name:MICKLES
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7778 EMILE ST
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70807-5633
Mailing Address - Country:US
Mailing Address - Phone:404-245-8839
Mailing Address - Fax:
Practice Address - Street 1:1718 N FOSTER DR STE B
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-1076
Practice Address - Country:US
Practice Address - Phone:225-465-3669
Practice Address - Fax:225-465-3687
Is Sole Proprietor?:No
Enumeration Date:2015-03-10
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPST020614183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist