1922166651 NPI number — MS. MIGNON ELISSE MCNICOL LISW

Table of content: MS. MIGNON ELISSE MCNICOL LISW (NPI 1922166651)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922166651 NPI number — MS. MIGNON ELISSE MCNICOL LISW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCNICOL
Provider First Name:
MIGNON
Provider Middle Name:
ELISSE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LISW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MCNICOL
Provider Other First Name:
LELA
Provider Other Middle Name:
MIGNON
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
LISW
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1922166651
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
713 6TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87701
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-429-0588
Provider Business Mailing Address Fax Number:
505-425-6236

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
713 6TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-429-0588
Provider Business Practice Location Address Fax Number:
505-425-6236
Provider Enumeration Date:
12/05/2006

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: 1041C0700X , with the licence number:  I2153 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000F5787 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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