Provider Demographics
NPI:1124317052
Name:MIKELL, COCQUESE (NURSE/LPN)
Entity type:Individual
Prefix:
First Name:COCQUESE
Middle Name:
Last Name:MIKELL
Suffix:
Gender:F
Credentials:NURSE/LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:843 SWEETWATER WAY
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-3785
Mailing Address - Country:US
Mailing Address - Phone:678-891-8014
Mailing Address - Fax:
Practice Address - Street 1:843 SWEETWATER WAY
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-3785
Practice Address - Country:US
Practice Address - Phone:678-891-8014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-31
Last Update Date:2011-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN071036164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse