MEDICARE: LYNASHIA MICKENS

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	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1588454136
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LYNASHIA MICKENS

Provider Business Mailing Address
First Line	:	3158 BALSAM LAKE DR
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43219-7311
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3158 BALSAM LAKE DR
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43219-7311
Country	:	US
Telephone Number	:	252-333-7431
Fax Number	:

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

Provider Enumeration Date	:	05/07/2025
Last Update Date	:	05/07/2025

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Directions to “ LYNASHIA MICKENS ” Practice Location

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