Provider Demographics
NPI:1801360318
Name:MICKLE, KEVIN (FNP)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:
Last Name:MICKLE
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 211699
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55121-3699
Mailing Address - Country:US
Mailing Address - Phone:866-849-0692
Mailing Address - Fax:888-973-8821
Practice Address - Street 1:20405 STATE HIGHWAY 249 STE 325
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77070-2893
Practice Address - Country:US
Practice Address - Phone:866-849-0692
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-17
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10007611363L00000X
NY343949363LF0000X
TX1098789363LF0000X
AZ295819363LF0000X
FLAPRN11023651363LF0000X
NC5019513363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner