Healthcare Provider Details

I. General information

NPI: 1699838623
Provider Name (Legal Business Name): MICHELLE ANNE BRANNICK DC, ND
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 11/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1013 E 31ST ST
LAGRANGE PARK IL
60526-1218
US

IV. Provider business mailing address

1650 E MAIN ST
ST. CHARLES IL
60174-2373
US

V. Phone/Fax

Practice location:
  • Phone: 708-447-2468
  • Fax: 630-444-1656
Mailing address:
  • Phone: 630-444-0066
  • Fax: 630-444-1656

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NI0900X
TaxonomyInternist Chiropractor
License Number038010197
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License Number038010197
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number038010197
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: