Healthcare Provider Details

I. General information

NPI: 1104027861
Provider Name (Legal Business Name): ASHLEE DIANE MICKELSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2007
Last Update Date: 11/04/2021
Certification Date: 11/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3919 N MAPLE ST
SPOKANE WA
99205-1349
US

IV. Provider business mailing address

611 N IRON BRIDGE WAY
SPOKANE WA
99202-4932
US

V. Phone/Fax

Practice location:
  • Phone: 509-444-8888
  • Fax: 509-444-7806
Mailing address:
  • Phone: 509-444-8888
  • Fax: 509-444-7806

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD60458815
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: