Healthcare Provider Details

I. General information

NPI: 1679403802
Provider Name (Legal Business Name): EMILY MIKKELSEN
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2026
Last Update Date: 05/20/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 W 4TH ST
BOONE IA
50036-3305
US

IV. Provider business mailing address

112 W 4TH ST
BOONE IA
50036-3305
US

V. Phone/Fax

Practice location:
  • Phone: 515-432-1393
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: