Healthcare Provider Details

I. General information

NPI: 1518081686
Provider Name (Legal Business Name): COLLEEN ANN MIKULA NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 01/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28800 RYAN RD SUITE 320
WARREN MI
48092-4272
US

IV. Provider business mailing address

1 WESTBROOK CORPORATE CTR SUITE 300
WESTCHESTER IL
60154-5701
US

V. Phone/Fax

Practice location:
  • Phone: 877-906-9699
  • Fax: 800-499-9260
Mailing address:
  • Phone: 708-375-3075
  • Fax: 800-499-9260

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number209002055
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: