Healthcare Provider Details

I. General information

NPI: 1891007688
Provider Name (Legal Business Name): MICHELLE LAUREN ZICKEL BLEW O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MICHELLE LAUREN ZICKEL O.D.

II. Dates (important events)

Enumeration Date: 07/08/2010
Last Update Date: 09/11/2024
Certification Date: 09/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

183 PORT RD STE B
KENNEBUNK ME
04043-7735
US

IV. Provider business mailing address

183 PORT RD STE B
KENNEBUNK ME
04043-7735
US

V. Phone/Fax

Practice location:
  • Phone: 207-216-9937
  • Fax: 207-216-9939
Mailing address:
  • Phone: 207-216-9937
  • Fax: 207-216-9939

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046010377
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4902
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1048
License Number StateME
# 4
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOEG002586
License Number StatePA
# 5
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number1048
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: