Provider Demographics
NPI:1558197251
Name:MIKKELSON, ROXANNE LUELLA (LPN)
Entity type:Individual
Prefix:MRS
First Name:ROXANNE
Middle Name:LUELLA
Last Name:MIKKELSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17643 BURROS LN NW
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:56326-8194
Mailing Address - Country:US
Mailing Address - Phone:320-808-6489
Mailing Address - Fax:
Practice Address - Street 1:410 30TH AVE E
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308-4769
Practice Address - Country:US
Practice Address - Phone:320-759-2640
Practice Address - Fax:612-725-1076
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-10
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNL046696-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse