Provider Demographics
NPI:1437326295
Name:KING, MICKRA HAMILTON
Entity type:Individual
Prefix:
First Name:MICKRA
Middle Name:HAMILTON
Last Name:KING
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MICKRA
Other - Middle Name:KAY
Other - Last Name:HAMILTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1679 COONSKIN DR
Mailing Address - Street 2:130TH MEDICAL GROUP
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25311-1023
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:304-341-6252
Practice Address - Street 1:1679 COONSKIN DR
Practice Address - Street 2:130TH MEDICAL GROUP
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25311-1023
Practice Address - Country:US
Practice Address - Phone:304-341-6252
Practice Address - Fax:304-341-6252
Is Sole Proprietor?:No
Enumeration Date:2008-05-12
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVA: 0221231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist