Basic Information
| Provider Information | |||||||||
| NPI: | 1699850446 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MIKKALSON | ||||||||
| FirstName: | GENELL | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | CNM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 234 ROXBURY RD | ||||||||
| Address2: | |||||||||
| City: | MARLBOROUGH | ||||||||
| State: | NH | ||||||||
| PostalCode: | 034552216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6038769448 | ||||||||
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| Practice Location | |||||||||
| Address1: | 580 COURT ST | ||||||||
| Address2: | |||||||||
| City: | KEENE | ||||||||
| State: | NH | ||||||||
| PostalCode: | 034311718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6033545454 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | 048845-23-01 | NH | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 048845-23-01 | 01 | NH | ARNP-CERTIFIED NURSE MIDW | OTHER | 048845-21 | 01 | NH | REGISTERED NURSE | OTHER |