Provider Demographics
NPI:1124897228
Name:MICKELSON, KATE NAOMI (MED)
Entity type:Individual
Prefix:
First Name:KATE
Middle Name:NAOMI
Last Name:MICKELSON
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CAMINO A SUMIYA #3 INT. 13
Mailing Address - Street 2:
Mailing Address - City:JIUTEPEC
Mailing Address - State:MORELOS
Mailing Address - Zip Code:62560
Mailing Address - Country:MX
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:CAMINO A SUMIYA #3 INT. 13
Practice Address - Street 2:
Practice Address - City:JIUTEPEC
Practice Address - State:MORELOS
Practice Address - Zip Code:62560
Practice Address - Country:MX
Practice Address - Phone:580-812-0910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-29
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator