1114570298 NPI number — MRS. AMANDA JUNE INAS MIKHAEIL PMHNP

Table of content: MRS. AMANDA JUNE INAS MIKHAEIL PMHNP (NPI 1114570298)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114570298 NPI number — MRS. AMANDA JUNE INAS MIKHAEIL PMHNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MIKHAEIL
Provider First Name:
AMANDA
Provider Middle Name:
JUNE INAS
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PMHNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114570298
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/18/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1020 4TH ST NE APT 2
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STAPLES
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56479-3352
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-296-2639
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14241 GRAND OAKS DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BAXTER
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56425-8749
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-316-3101
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/18/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP0808X , with the licence number:  6720 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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