Provider Demographics
NPI:1164263489
Name:MICKARTZ, COLBY BETH (AG-ACNP)
Entity type:Individual
Prefix:
First Name:COLBY
Middle Name:BETH
Last Name:MICKARTZ
Suffix:
Gender:F
Credentials:AG-ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 911
Mailing Address - Street 2:
Mailing Address - City:BRATTLEBORO
Mailing Address - State:VT
Mailing Address - Zip Code:05302-0911
Mailing Address - Country:US
Mailing Address - Phone:207-303-3200
Mailing Address - Fax:207-250-2140
Practice Address - Street 1:11 ROCK ROW STE 120
Practice Address - Street 2:
Practice Address - City:WESTBROOK
Practice Address - State:ME
Practice Address - Zip Code:04092-4877
Practice Address - Country:US
Practice Address - Phone:207-303-3300
Practice Address - Fax:207-250-2137
Is Sole Proprietor?:No
Enumeration Date:2024-06-03
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MECNP241192363LA2100X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care