Healthcare Provider Details

I. General information

NPI: 1326966243
Provider Name (Legal Business Name): MICHELLE M STATELY CHW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2026
Last Update Date: 07/08/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 5TH ST NW STE 2A
BEMIDJI MN
56601-2932
US

IV. Provider business mailing address

15855 MAIN AVE
RED LAKE MN
56671
US

V. Phone/Fax

Practice location:
  • Phone: 218-444-2718
  • Fax:
Mailing address:
  • Phone: 218-444-2718
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: