Provider Demographics
NPI:1336611425
Name:STEGEN, MIKKALELLA J (FAMILY PRACTIONER)
Entity Type:Individual
Prefix:
First Name:MIKKALELLA
Middle Name:J
Last Name:STEGEN
Suffix:
Gender:F
Credentials:FAMILY PRACTIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2669 SCENIC DR
Mailing Address - Street 2:
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88310-8734
Mailing Address - Country:US
Mailing Address - Phone:575-439-6100
Mailing Address - Fax:
Practice Address - Street 1:2669 SCENIC DR
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-8734
Practice Address - Country:US
Practice Address - Phone:575-493-6100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-29
Last Update Date:2018-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM54557363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner