Healthcare Provider Details

I. General information

NPI: 1417789025
Provider Name (Legal Business Name): MICHAELA WOLVERTON PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2024
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 SHADY OAKS ST
LAKE ORION MI
48362-2571
US

IV. Provider business mailing address

555 SHADY OAKS ST
LAKE ORION MI
48362-2571
US

V. Phone/Fax

Practice location:
  • Phone: 248-935-4707
  • Fax:
Mailing address:
  • Phone: 248-935-4707
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209.033676
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: