Provider Demographics
NPI:1992401640
Name:MIKKELSEN, KENDALL NICOLE (MS, LAT, ATC)
Entity type:Individual
Prefix:
First Name:KENDALL
Middle Name:NICOLE
Last Name:MIKKELSEN
Suffix:
Gender:F
Credentials:MS, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11795 ANTIETAM RD
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-1214
Mailing Address - Country:US
Mailing Address - Phone:210-422-6811
Mailing Address - Fax:
Practice Address - Street 1:19790 ASHBURN RD
Practice Address - Street 2:
Practice Address - City:ASHBURN
Practice Address - State:VA
Practice Address - Zip Code:20147-5636
Practice Address - Country:US
Practice Address - Phone:571-209-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-03
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program