1881106979 NPI number — MRS. MIKYLA FELICIANO ANDERSON PT, DPT

Table of content: MRS. MIKYLA FELICIANO ANDERSON PT, DPT (NPI 1881106979)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881106979 NPI number — MRS. MIKYLA FELICIANO ANDERSON PT, DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANDERSON
Provider First Name:
MIKYLA
Provider Middle Name:
FELICIANO
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PT, DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
VASTINE
Provider Other First Name:
MIKYLA
Provider Other Middle Name:
FELICIANO
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PT, DPT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1881106979
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/29/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4705 BAYVIEW DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PLANO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75093-1938
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
682-553-0258
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1600 FM 544 # 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEWISVILLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75056-4591
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-295-5677
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/29/2017

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: 225100000X , with the licence number:  1290753 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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