1922508092 NPI number — PENNY DELYNNE-ROSENBROOK MICKEL

Table of content: PENNY DELYNNE-ROSENBROOK MICKEL (NPI 1922508092)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922508092 NPI number — PENNY DELYNNE-ROSENBROOK MICKEL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MICKEL
Provider First Name:
PENNY
Provider Middle Name:
DELYNNE-ROSENBROOK
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:
ROSENBROOK
Provider Other First Name:
PENNY
Provider Other Middle Name:
DELYNNE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
COUNSELOR
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1922508092
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/15/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15361 ELM ROW RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALBION
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49224-9610
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
517-206-2517
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
155 GARFIELD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BATTLE CREEK
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49037-3407
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-968-9287
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/15/2018

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: 101YP2500X , with the licence number:  6401014355 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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