MEDICARE: DEIRDRE MAE MICKER N.P.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	F420349	NY
2	363LW0102X	Women's Health Nurse Practitioner	F420349	NY
3	363LF0000X	Family Nurse Practitioner	F420349	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1467622084
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEIRDRE MAE MICKER N.P.

Provider Business Mailing Address
First Line	:	1 WEBSTER AVE STE 202
Second Line	:
City	:	POUGHKEEPSIE
State	:	NY
Zip	:	12601-1362
Country	:	US
Telephone Number	:	845-483-5741
Fax Number	:	845-483-5713

Provider Business Practice Location Address
First Line	:	9 HDSN VLY PROF PLZ
Second Line	:
City	:	NEWBURGH
State	:	NY
Zip	:	12550-3150
Country	:	US
Telephone Number	:	845-561-0990
Fax Number	:	845-562-1439

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/11/2008
Last Update Date	:	07/19/2021

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