Provider Demographics
NPI:1700450814
Name:MIKELL, MARY (RN BSN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:MIKELL
Suffix:
Gender:F
Credentials:RN BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16005 AVALON AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH HOLLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60473-1865
Mailing Address - Country:US
Mailing Address - Phone:708-964-6135
Mailing Address - Fax:
Practice Address - Street 1:16005 AVALON AVE
Practice Address - Street 2:
Practice Address - City:SOUTH HOLLAND
Practice Address - State:IL
Practice Address - Zip Code:60473-1865
Practice Address - Country:US
Practice Address - Phone:708-964-6135
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-14
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041398510163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse