Healthcare Provider Details

I. General information

NPI: 1619702040
Provider Name (Legal Business Name): LISA MARIE MICHALSKI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2024
Last Update Date: 09/05/2024
Certification Date: 09/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 E DOUGLAS RD
MISHAWAKA IN
46545-1464
US

IV. Provider business mailing address

925 POTTER POINT DR
SOUTH BEND IN
46614-3469
US

V. Phone/Fax

Practice location:
  • Phone: 574-335-6700
  • Fax:
Mailing address:
  • Phone: 574-299-3863
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2023058906
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: