Provider Demographics
NPI:1427886209
Name:FOX, MICKEY MICHELLE (FNP-BC)
Entity type:Individual
Prefix:
First Name:MICKEY
Middle Name:MICHELLE
Last Name:FOX
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6989 SVL BOX
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-5186
Mailing Address - Country:US
Mailing Address - Phone:909-636-1582
Mailing Address - Fax:
Practice Address - Street 1:17450 MAIN ST STE D
Practice Address - Street 2:
Practice Address - City:HESPERIA
Practice Address - State:CA
Practice Address - Zip Code:92345-6262
Practice Address - Country:US
Practice Address - Phone:760-493-2929
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-23
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95109643163WM0705X
CA95031507363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical