Provider Demographics
NPI:1215473749
Name:MIKULICH, MERIDITH (MPH, CNM, RN)
Entity type:Individual
Prefix:MS
First Name:MERIDITH
Middle Name:
Last Name:MIKULICH
Suffix:
Gender:F
Credentials:MPH, CNM, RN
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 1559
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11794-4142
Mailing Address - Country:US
Mailing Address - Phone:973-222-0412
Mailing Address - Fax:
Practice Address - Street 1:UNIVERSITY ASSOCIATES IN OB/GYN HSC LEVEL 9, ROOM 020
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794
Practice Address - Country:US
Practice Address - Phone:973-222-0412
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-08
Last Update Date:2021-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001764176B00000X, 367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No176B00000XOther Service ProvidersMidwife