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General NPI Number Information
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NPI Number | 1194779744
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Entity Type | Individual
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Provider Name | LAURIE ELIZABETH MICKLE MD
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Gender | Female
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Dates
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Enumeration Date | 05/19/2006
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Last Update Date | 05/03/2014
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Provider Practice Location Address
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Address Line | 10512 N 110TH EAST AVE SUITE 300
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City | OWASSO
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State | OK
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Zip | 74055-6636
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Country | US
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Telephone | 918-376-8901
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Fax | 918-376-8939
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Provider Business Mailing Address
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Address Line | 10512 N 110TH EAST AVE SUITE 300
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City | OWASSO
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State | OK
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Zip | 74055-6636
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Country | US
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Telephone | 918-376-8901
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Fax | 918-376-8939
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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 | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 17332
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License Number State | OK
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