Healthcare Provider Details

I. General information

NPI: 1790580553
Provider Name (Legal Business Name): MICHELLE ELAINE DEROME
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/17/2025
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3024 SNELLING AVE
MINNEAPOLIS MN
55406-1911
US

IV. Provider business mailing address

1300 YALE PL APT 208
MINNEAPOLIS MN
55403-2157
US

V. Phone/Fax

Practice location:
  • Phone: 612-775-4900
  • Fax:
Mailing address:
  • Phone: 262-226-6049
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: