Healthcare Provider Details

I. General information

NPI: 1487954079
Provider Name (Legal Business Name): LATOYA DENISE MICKLE APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2010
Last Update Date: 09/17/2024
Certification Date: 09/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 DOCTOR CIR
COLUMBIA SC
29203-6502
US

IV. Provider business mailing address

111 DOCTOR CIR
COLUMBIA SC
29203-6502
US

V. Phone/Fax

Practice location:
  • Phone: 800-491-0909
  • Fax:
Mailing address:
  • Phone: 800-491-0909
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4225
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: