1285431361 NPI number — AMANDA LYNNE MICKAVICZ SICKORA

Table of content: AMANDA LYNNE MICKAVICZ SICKORA (NPI 1285431361)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285431361 NPI number — AMANDA LYNNE MICKAVICZ SICKORA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MICKAVICZ SICKORA
Provider First Name:
AMANDA
Provider Middle Name:
LYNNE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MICKAVICZ
Provider Other First Name:
AMANDA
Provider Other Middle Name:
LYNNE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1285431361
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/26/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8155 JEFFERSON HWY APT 1104
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BATON ROUGE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70809-1618
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
682-970-7101
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8155 JEFFERSON HWY APT 1104
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BATON ROUGE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70809-1618
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
682-970-7101
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/26/2025

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: 171M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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