Provider Demographics
NPI:1013916915
Name:MICKELSON, BROOKANNE J (FNP-BC)
Entity Type:Individual
Prefix:
First Name:BROOKANNE
Middle Name:J
Last Name:MICKELSON
Suffix:
Gender:F
Credentials:FNP-BC
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 912042
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84791-2042
Mailing Address - Country:US
Mailing Address - Phone:435-656-2424
Mailing Address - Fax:435-656-2828
Practice Address - Street 1:301 N 200 E STE 2A
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-3040
Practice Address - Country:US
Practice Address - Phone:435-688-7246
Practice Address - Fax:435-688-1363
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT222657-4405363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTS73682Medicare UPIN
UTS73682Medicare UPIN