Provider Demographics
NPI:1710585518
Name:STANLEY, MIKAYLA (LPN)
Entity Type:Individual
Prefix:
First Name:MIKAYLA
Middle Name:
Last Name:STANLEY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6489 STATE ROUTE 104A
Mailing Address - Street 2:
Mailing Address - City:RED CREEK
Mailing Address - State:NY
Mailing Address - Zip Code:13143-3106
Mailing Address - Country:US
Mailing Address - Phone:315-576-5689
Mailing Address - Fax:
Practice Address - Street 1:6489 STATE ROUTE 104A
Practice Address - Street 2:
Practice Address - City:RED CREEK
Practice Address - State:NY
Practice Address - Zip Code:13143-3106
Practice Address - Country:US
Practice Address - Phone:315-576-5689
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-14
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY335716-01164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse