Provider Demographics
NPI:1437783313
Name:MICKENS, BRENDA WILSON
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:WILSON
Last Name:MICKENS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4917 DAFFODIL CIR
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-3558
Mailing Address - Country:US
Mailing Address - Phone:804-839-3642
Mailing Address - Fax:804-303-0810
Practice Address - Street 1:4917 DAFFODIL CIR
Practice Address - Street 2:
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23060-3558
Practice Address - Country:US
Practice Address - Phone:804-839-3642
Practice Address - Fax:804-303-0810
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-28
Last Update Date:2020-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health