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General NPI Number Information
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NPI Number | 1457967002
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Entity Type | Individual
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Provider Name | RECIA MICKENS-LOPEZ APRN-CNP
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Gender | Female
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Dates
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Enumeration Date | 09/18/2020
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Last Update Date | 09/18/2020
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Provider Practice Location Address
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Address Line | 717 S 30TH ST
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City | HEATH
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State | OH
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Zip | 43056-1294
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Country | US
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Telephone | 248-470-3247
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Fax |
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Provider Business Mailing Address
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Address Line | 359 OAK HILL DR
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City | WESTERVILLE
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State | OH
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Zip | 43081-3420
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Country | US
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Telephone | 248-470-3247
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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 | 363LA2200X
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Taxonomy Name | Adult Health Nurse Practitioner
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License Number | 026471
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License Number State | OH
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Taxonomy #2
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Taxonomy Code | 363LG0600X
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Taxonomy Name | Gerontology Nurse Practitioner
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License Number | 026471
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License Number State | OH
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