Provider Demographics
NPI:1710454707
Name:OWEN, MIKAYLA NICOLE
Entity Type:Individual
Prefix:
First Name:MIKAYLA
Middle Name:NICOLE
Last Name:OWEN
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 1:4504 USEPPA DR
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34203-3139
Mailing Address - Country:US
Mailing Address - Phone:256-473-2525
Mailing Address - Fax:
Practice Address - Street 1:4504 USEPPA DR
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34203-3139
Practice Address - Country:US
Practice Address - Phone:256-473-2525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-27
Last Update Date:2018-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer