Provider Demographics
NPI:1073367215
Name:MICKENS, TERAN MICHELLE
Entity type:Individual
Prefix:
First Name:TERAN
Middle Name:MICHELLE
Last Name:MICKENS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7150 COUNTRY WALK DR
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:OH
Mailing Address - Zip Code:45005-3992
Mailing Address - Country:US
Mailing Address - Phone:412-225-0959
Mailing Address - Fax:
Practice Address - Street 1:750 E ADAMS ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-2306
Practice Address - Country:US
Practice Address - Phone:315-464-8948
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-15
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program