Basic Information
| Provider Information | |||||||||
| NPI: | 1336752492 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MICK | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | FNP, RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 213 S JEFFERSON ST STE 625 | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240111713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5402245516 | ||||||||
| FaxNumber: | 5402245684 | ||||||||
| Practice Location | |||||||||
| Address1: | 150 MARKET RIDGE LN | ||||||||
| Address2: | |||||||||
| City: | DALEVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240833258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5409660400 | ||||||||
| FaxNumber: | 5409926669 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2020 | ||||||||
| LastUpdateDate: | 01/07/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 0024180057 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 163W00000X | 0001228709 | VA | N | Nursing Service Providers | Registered Nurse |
No ID Information.