Provider Demographics
NPI:1851529077
Name:MICKENS, SUSAN (CPNP)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:
Last Name:MICKENS
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 TRANCAS ST
Mailing Address - Street 2:SUITE 270
Mailing Address - City:NAPA
Mailing Address - State:CA
Mailing Address - Zip Code:94558-2900
Mailing Address - Country:US
Mailing Address - Phone:707-252-1076
Mailing Address - Fax:707-252-7923
Practice Address - Street 1:1100 TRANCAS ST
Practice Address - Street 2:SUITE 270
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94558-2900
Practice Address - Country:US
Practice Address - Phone:707-252-1076
Practice Address - Fax:707-252-7923
Is Sole Proprietor?:No
Enumeration Date:2009-06-25
Last Update Date:2009-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA490368364SP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA39182Medicare UPIN