Healthcare Provider Details

I. General information

NPI: 1326620717
Provider Name (Legal Business Name): MICHELLE JACQUELINE WILMES AGPCNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MICHELLE JACQUELINE KERR RN

II. Dates (important events)

Enumeration Date: 04/25/2021
Last Update Date: 11/26/2021
Certification Date: 11/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 RENAISSANCE CTR STE 2600
DETROIT MI
48243-1502
US

IV. Provider business mailing address

400 RENAISSANCE CTR STE 2600
DETROIT MI
48243-1502
US

V. Phone/Fax

Practice location:
  • Phone: 877-702-6863
  • Fax:
Mailing address:
  • Phone: 877-702-6863
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number4704321495
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4704321495
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: