Provider Demographics
NPI:1972825537
Name:PERKINS, MICALENA ROSE (MSN, APRN, CPNP)
Entity Type:Individual
Prefix:
First Name:MICALENA
Middle Name:ROSE
Last Name:PERKINS
Suffix:
Gender:F
Credentials:MSN, APRN, CPNP
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 30180
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84130-0180
Mailing Address - Country:US
Mailing Address - Phone:801-662-1000
Mailing Address - Fax:
Practice Address - Street 1:1501 HILAND AVE
Practice Address - Street 2:
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-2688
Practice Address - Country:US
Practice Address - Phone:208-677-6080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-24
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4938107-4405363LP0200X, 363L00000X
ID71285363L00000X
UT4938107-8900363L00000X
CA19447363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics