Provider Demographics
NPI:1285431361
Name:MICKAVICZ SICKORA, AMANDA LYNNE
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:LYNNE
Last Name:MICKAVICZ SICKORA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:LYNNE
Other - Last Name:MICKAVICZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8155 JEFFERSON HWY APT 1104
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-1618
Mailing Address - Country:US
Mailing Address - Phone:682-970-7101
Mailing Address - Fax:
Practice Address - Street 1:8155 JEFFERSON HWY APT 1104
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-1618
Practice Address - Country:US
Practice Address - Phone:682-970-7101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-26
Last Update Date:2025-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty