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General NPI Number Information
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NPI Number | 1508338732
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Entity Type | Individual
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Provider Name | ERIN LEAH MICKELSON
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Gender | Female
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Dates
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Enumeration Date | 12/28/2018
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Last Update Date | 12/28/2018
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Provider Practice Location Address
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Address Line | 1542 MARVIN GARDENS LN
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City | PRESCOTT
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State | AZ
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Zip | 86301-5528
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Country | US
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Telephone | 928-312-2011
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Fax |
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Provider Business Mailing Address
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Address Line | 10 BROADMOOR
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City | PRESCOTT
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State | AZ
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Zip | 86305-5086
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Country | US
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Telephone | 928-445-2692
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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 | 207QA0505X
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Taxonomy Name | Adult Medicine Physician
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License Number | 137284
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License Number State | AZ
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