MEDICARE: MRS. MICHELLE ELAINE SULTAGE CRNP-FAMILY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	R161602	MD

General Provider Information

NPI Number	:	1093014656
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MICHELLE ELAINE SULTAGE CRNP-FAMILY

Provider Business Mailing Address
First Line	:	28105 THREE NOTCH RD
Second Line	:	1C
City	:	MECHANICSVILLE
State	:	MD
Zip	:	20659-3235
Country	:	US
Telephone Number	:	301-290-1510
Fax Number	:

Provider Business Practice Location Address
First Line	:	28105 THREE NOTCH RD
Second Line	:	1C
City	:	MECHANICSVILLE
State	:	MD
Zip	:	20659-3235
Country	:	US
Telephone Number	:	301-290-1510
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/22/2011
Last Update Date	:	04/19/2015

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