Provider Demographics
NPI:1457173320
Name:GOCKEN, MICKIE LYNN (AGNP-C)
Entity type:Individual
Prefix:
First Name:MICKIE
Middle Name:LYNN
Last Name:GOCKEN
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 N E ST
Mailing Address - Street 2:
Mailing Address - City:LAKEVIEW
Mailing Address - State:OR
Mailing Address - Zip Code:97630-1524
Mailing Address - Country:US
Mailing Address - Phone:320-241-5465
Mailing Address - Fax:
Practice Address - Street 1:8 N E ST
Practice Address - Street 2:
Practice Address - City:LAKEVIEW
Practice Address - State:OR
Practice Address - Zip Code:97630-1524
Practice Address - Country:US
Practice Address - Phone:320-241-5465
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-30
Last Update Date:2025-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAIP61550574363LG0600X
OR10043127363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology