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General NPI Number Information
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NPI Number | 1093433641
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Entity Type | Individual
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Provider Name | JARLISA MICKEY RN, A-GPCNP-C
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Gender | Female
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Dates
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Enumeration Date | 08/19/2022
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Last Update Date | 08/26/2024
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Provider Practice Location Address
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Address Line | 10175 LITTLE PATUXENT PKWY
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City | COLUMBIA
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State | MD
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Zip | 21044-2655
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Country | US
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Telephone | 501-553-1153
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Fax |
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Provider Business Mailing Address
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Address Line | 10175 LITTLE PATUXENT PKWY
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City | COLUMBIA
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State | MD
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Zip | 21044-2655
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LG0600X
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Taxonomy Name | Gerontology Nurse Practitioner
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License Number | 220528
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License Number State | AR
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