Healthcare Provider Details

I. General information

NPI: 1275069585
Provider Name (Legal Business Name): MICHELLE MICLEA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2017
Last Update Date: 05/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9815 DIXIE HWY
IRA MI
48023-2817
US

IV. Provider business mailing address

9815 DIXIE HWY
IRA MI
48023-2817
US

V. Phone/Fax

Practice location:
  • Phone: 313-605-7465
  • Fax:
Mailing address:
  • Phone: 313-605-7465
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number4704231675
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: