Healthcare Provider Details

I. General information

NPI: 1225222946
Provider Name (Legal Business Name): MICHELLE M GILLMORE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MICHELLE M HAUSER NP

II. Dates (important events)

Enumeration Date: 09/06/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 E MICHIGAN AVE STE 240
JACKSON MI
49201-1855
US

IV. Provider business mailing address

PO BOX 67000 DEPARTMENT 272801
DETROIT MI
48267-2728
US

V. Phone/Fax

Practice location:
  • Phone: 517-205-1591
  • Fax:
Mailing address:
  • Phone: 517-841-7490
  • Fax: 517-841-6917

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4704211845
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704211845
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: