Provider Demographics
NPI:1548346935
Name:MYKKANEN, DEBRA COLLEEN (FNP)
Entity type:Individual
Prefix:MS
First Name:DEBRA
Middle Name:COLLEEN
Last Name:MYKKANEN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 W IRONWOOD DR
Mailing Address - Street 2:SUITE 155
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2656
Mailing Address - Country:US
Mailing Address - Phone:208-667-0585
Mailing Address - Fax:208-667-0876
Practice Address - Street 1:700 W IRONWOOD DR
Practice Address - Street 2:SUITE 155
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2656
Practice Address - Country:US
Practice Address - Phone:208-667-0585
Practice Address - Fax:208-667-0876
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP306A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1548346935Medicaid
ID000010016720OtherREGENCE BLUE SHIELD
ID000010016721OtherREGENCE BLUE SHIELD
ID004376300Medicaid
WA9645896Medicaid
IDNPPR4OtherBLUE CROSS OF IDAHO
AKNP772IDMedicaid
IDNPKN7OtherBLUE CROSS