Provider Demographics
NPI:1023697000
Name:MICKIE, TAMIKA
Entity type:Individual
Prefix:
First Name:TAMIKA
Middle Name:
Last Name:MICKIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3725 ROSEMONT AVE
Mailing Address - Street 2:
Mailing Address - City:DREXEL HILL
Mailing Address - State:PA
Mailing Address - Zip Code:19026-3009
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:680 BLAIR MILL RD
Practice Address - Street 2:
Practice Address - City:HORSHAM
Practice Address - State:PA
Practice Address - Zip Code:19044-2223
Practice Address - Country:US
Practice Address - Phone:484-781-5933
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-06
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP022939363LG0600X
PARN635596163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No163W00000XNursing Service ProvidersRegistered Nurse