Provider Demographics
NPI:1699719765
Name:PRESTON, MICKIE D (RN, APN)
Entity type:Individual
Prefix:
First Name:MICKIE
Middle Name:D
Last Name:PRESTON
Suffix:
Gender:F
Credentials:RN, APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5115 MARYLAND WAY
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-1200
Mailing Address - Country:US
Mailing Address - Phone:615-346-8468
Mailing Address - Fax:
Practice Address - Street 1:5115 MARYLAND WAY
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:TN
Practice Address - Zip Code:37027-1200
Practice Address - Country:US
Practice Address - Phone:615-346-8468
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN11828363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4125091OtherBCBST
TN36434112Medicaid
TN10350I2149Medicare PIN
TN4125091OtherBCBST