Provider Demographics
NPI:1013105733
Name:MICLAT, AMY REYES (RN, MS, CCRN, APRN-B)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:REYES
Last Name:MICLAT
Suffix:
Gender:F
Credentials:RN, MS, CCRN, APRN-B
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6414 LUSSIER DR
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77479-5087
Mailing Address - Country:US
Mailing Address - Phone:281-565-6414
Mailing Address - Fax:
Practice Address - Street 1:6565 FANNIN ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2703
Practice Address - Country:US
Practice Address - Phone:713-441-4999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-09
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX513374363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1013105733OtherBLUE CROSS BLUE SHIED