Provider Demographics
NPI:1700507167
Name:MICKNA, DORY (FNP-C)
Entity Type:Individual
Prefix:
First Name:DORY
Middle Name:
Last Name:MICKNA
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11550 ROPP RD
Mailing Address - Street 2:
Mailing Address - City:TREMONT
Mailing Address - State:IL
Mailing Address - Zip Code:61568-8803
Mailing Address - Country:US
Mailing Address - Phone:309-202-7808
Mailing Address - Fax:
Practice Address - Street 1:2301 COURT ST
Practice Address - Street 2:
Practice Address - City:PEKIN
Practice Address - State:IL
Practice Address - Zip Code:61554-5304
Practice Address - Country:US
Practice Address - Phone:309-308-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-06
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209025883363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner