Provider Demographics
NPI:1912255001
Name:MAINE, MIKELLA B (FNP)
Entity Type:Individual
Prefix:
First Name:MIKELLA
Middle Name:B
Last Name:MAINE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:MIKELLA
Other - Middle Name:BLAKE
Other - Last Name:OWEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:407 DEERFIELD CIR
Mailing Address - Street 2:
Mailing Address - City:CHURCH HILL
Mailing Address - State:TN
Mailing Address - Zip Code:37642-3423
Mailing Address - Country:US
Mailing Address - Phone:423-361-2305
Mailing Address - Fax:
Practice Address - Street 1:301 MED TECH PKWY STE 240
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-2641
Practice Address - Country:US
Practice Address - Phone:423-794-5520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-21
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN144170163W00000X
TN16877363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse