Provider Demographics
NPI:1760015119
Name:LANG, MIKAYLAH
Entity Type:Individual
Prefix:
First Name:MIKAYLAH
Middle Name:
Last Name:LANG
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 1:4505 GEORGEWASHINGTON HWY
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23702
Mailing Address - Country:US
Mailing Address - Phone:757-956-6200
Mailing Address - Fax:757-410-4210
Practice Address - Street 1:4505 GEORGEWASHINGTON HWY
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23702
Practice Address - Country:US
Practice Address - Phone:757-956-6200
Practice Address - Fax:757-410-4210
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-13
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
314000000X, 385H00000X
VA3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No385H00000XRespite Care FacilityRespite Care