Healthcare Provider Details

I. General information

NPI: 1306507058
Provider Name (Legal Business Name): MICHELLE TREVINO PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2022
Last Update Date: 06/04/2025
Certification Date: 06/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

228 PLAZA DR STE D
LEHIGH ACRES FL
33936-6054
US

IV. Provider business mailing address

12509 STONE TOWER LOOP
FORT MYERS FL
33913-6781
US

V. Phone/Fax

Practice location:
  • Phone: 239-236-8784
  • Fax: 651-666-1619
Mailing address:
  • Phone: 651-336-6468
  • Fax: 651-666-1619

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number11017274
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: