Healthcare Provider Details

I. General information

NPI: 1124436217
Provider Name (Legal Business Name): MICHELLE WATHIER NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2014
Last Update Date: 10/17/2025
Certification Date: 10/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4900 BROADWAY
GARY IN
46408-4605
US

IV. Provider business mailing address

PO BOX 746721
ATLANTA GA
30374-6721
US

V. Phone/Fax

Practice location:
  • Phone: 219-237-5170
  • Fax:
Mailing address:
  • Phone: 312-733-9730
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number28167408A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: