Provider Demographics
NPI:1588115729
Name:MYKOL, DORENE (OWNER)
Entity type:Individual
Prefix:
First Name:DORENE
Middle Name:
Last Name:MYKOL
Suffix:
Gender:F
Credentials:OWNER
Other - Prefix:
Other - First Name:NEW
Other - Middle Name:TECH
Other - Last Name:MOBILITY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:4525 N 24TH ST STE 110
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-5299
Mailing Address - Country:US
Mailing Address - Phone:480-868-9069
Mailing Address - Fax:
Practice Address - Street 1:4525 N 24TH ST STE 110
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-5299
Practice Address - Country:US
Practice Address - Phone:480-868-9069
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-24
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor