Provider Demographics
NPI:1255339719
Name:MIKELL, CALLIE E (CNM)
Entity type:Individual
Prefix:
First Name:CALLIE
Middle Name:E
Last Name:MIKELL
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:967 48TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11219-2919
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:967 48TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11219-2919
Practice Address - Country:US
Practice Address - Phone:718-283-8867
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2014-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF000794-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02121075Medicaid
NY02121075Medicaid
NYP07791Medicare UPIN