1821170051 NPI number — MIKKLENA M MATTHEWS FNP

Table of content: MIKKLENA M MATTHEWS FNP (NPI 1821170051)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821170051 NPI number — MIKKLENA M MATTHEWS FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MATTHEWS
Provider First Name:
MIKKLENA
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP
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:
1821170051
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/14/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1898 FORT RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHERIDAN
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
82801-8320
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-672-3473
Provider Business Mailing Address Fax Number:
307-672-1939

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1898 FORT RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHERIDAN
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82801-8320
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-672-3473
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/19/2006

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: 363A00000X , with the licence number:  AP3293 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 1146 , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 39258 . This is a "BCBSNE FOR IOWA" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 100251147-00 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 254537 . This is a "MIDLANDS CHOICE FOR NERBASKA" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 39139 . This is a "BCBSNE" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 254537 . This is a "MIDLANDS CHOICE FOR IOWA" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".




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