Provider Demographics
NPI:1932467727
Name:MICKEY, JUSTIN RANDAL (PMHNP)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:RANDAL
Last Name:MICKEY
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3420 E CLARENDON AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-5758
Mailing Address - Country:US
Mailing Address - Phone:480-532-7765
Mailing Address - Fax:
Practice Address - Street 1:2500 E VAN BUREN ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85008-6037
Practice Address - Country:US
Practice Address - Phone:602-220-6078
Practice Address - Fax:602-220-6293
Is Sole Proprietor?:No
Enumeration Date:2012-04-30
Last Update Date:2012-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZTAP4472363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health