Healthcare Provider Details

I. General information

NPI: 1982655213
Provider Name (Legal Business Name): MICHELE GLORIA PARADIS APRN BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY RAPHAEL PARADIS APRN BC

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 10/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

803 4TH ST
JACKSON MN
56143-1056
US

IV. Provider business mailing address

803 4TH ST
JACKSON MN
56143-1056
US

V. Phone/Fax

Practice location:
  • Phone: 507-847-3571
  • Fax: 507-847-5664
Mailing address:
  • Phone: 507-847-3571
  • Fax: 507-847-5664

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number4704155091
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number121976-4
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: