Provider Demographics
NPI:1437725058
Name:MILLWOOD, MARK LANDON JR (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:LANDON
Last Name:MILLWOOD
Suffix:JR
Gender:
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 20970
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82003-7020
Mailing Address - Country:US
Mailing Address - Phone:307-634-2273
Mailing Address - Fax:307-773-8013
Practice Address - Street 1:5416 EDUCATION DR
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-4094
Practice Address - Country:US
Practice Address - Phone:307-778-3675
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-03
Last Update Date:2025-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY54163363L00000X, 363LP0808X
NH077749-23363LP0808X
COAPRN.0999772-NP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner