Provider Demographics
NPI:1861920407
Name:MICAH A LADNER FNP-C LLC
Entity type:Organization
Organization Name:MICAH A LADNER FNP-C LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICAH
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:LADNER
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:228-493-3404
Mailing Address - Street 1:PO BOX 6571
Mailing Address - Street 2:
Mailing Address - City:DIAMONDHEAD
Mailing Address - State:MS
Mailing Address - Zip Code:39525-6501
Mailing Address - Country:US
Mailing Address - Phone:228-493-3404
Mailing Address - Fax:
Practice Address - Street 1:22549 FENTON DEDEAUX RD
Practice Address - Street 2:
Practice Address - City:KILN
Practice Address - State:MS
Practice Address - Zip Code:39556-6576
Practice Address - Country:US
Practice Address - Phone:228-493-3404
Practice Address - Fax:228-493-3404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-26
Last Update Date:2017-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS901609363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty