Provider Demographics
NPI:1871619007
Name:MIKALS, MARISA ANN (DC)
Entity type:Individual
Prefix:DR
First Name:MARISA
Middle Name:ANN
Last Name:MIKALS
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2406 OWENS LANDING WAY NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30152-6551
Mailing Address - Country:US
Mailing Address - Phone:770-309-1816
Mailing Address - Fax:
Practice Address - Street 1:4900 IVEY RD NW
Practice Address - Street 2:SUITE 820
Practice Address - City:ACWORTH
Practice Address - State:GA
Practice Address - Zip Code:30101-4001
Practice Address - Country:US
Practice Address - Phone:770-975-9233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA007163111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor