Provider Demographics
NPI:1700988771
Name:HOUSTON, MICKEY LYNN (NP,APRN)
Entity Type:Individual
Prefix:
First Name:MICKEY
Middle Name:LYNN
Last Name:HOUSTON
Suffix:
Gender:F
Credentials:NP,APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:930 N SWITZER CANYON DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-4824
Mailing Address - Country:US
Mailing Address - Phone:928-779-5707
Mailing Address - Fax:928-779-5753
Practice Address - Street 1:930 N SWITZER CANYON DR
Practice Address - Street 2:SUITE 202
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-4824
Practice Address - Country:US
Practice Address - Phone:928-779-5707
Practice Address - Fax:928-779-5753
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2009-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT198439-4405363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT005777003Medicare PIN
UTQ69047Medicare UPIN