Provider Demographics
NPI:1750735957
Name:DAMMERMAN, MIKAYLA MICOLE
Entity type:Individual
Prefix:MISS
First Name:MIKAYLA
Middle Name:MICOLE
Last Name:DAMMERMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 KRATZINGER HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:COBDEN
Mailing Address - State:IL
Mailing Address - Zip Code:62920-3780
Mailing Address - Country:US
Mailing Address - Phone:618-697-8173
Mailing Address - Fax:
Practice Address - Street 1:105 KRATZINGER HOLLOW RD
Practice Address - Street 2:
Practice Address - City:COBDEN
Practice Address - State:IL
Practice Address - Zip Code:62920-3780
Practice Address - Country:US
Practice Address - Phone:618-697-8173
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-14
Last Update Date:2016-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer