Provider Demographics
NPI:1093433641
Name:MICKEY, JARLISA (RN, A-GPCNP-C)
Entity type:Individual
Prefix:
First Name:JARLISA
Middle Name:
Last Name:MICKEY
Suffix:
Gender:F
Credentials:RN, A-GPCNP-C
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Other - Middle Name:
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Mailing Address - Street 1:10175 LITTLE PATUXENT PKWY
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21044-2655
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10175 LITTLE PATUXENT PKWY
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-2655
Practice Address - Country:US
Practice Address - Phone:501-553-1153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-19
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AR220528363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology