Provider Demographics
NPI:1588954598
Name:MIKULAS, MARIAH LYNN (COTA)
Entity type:Individual
Prefix:
First Name:MARIAH
Middle Name:LYNN
Last Name:MIKULAS
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2724 FRANKLIN AVENUE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003
Mailing Address - Country:US
Mailing Address - Phone:719-469-4170
Mailing Address - Fax:
Practice Address - Street 1:2724 FRANKLIN AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-1330
Practice Address - Country:US
Practice Address - Phone:719-469-4170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-11
Last Update Date:2011-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO271089314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility