Healthcare Provider Details

I. General information

NPI: 1114675501
Provider Name (Legal Business Name): MICHELLE LYNN BLAND APRN, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SHELLEY LYNN BLAND APRN, FNP-C

II. Dates (important events)

Enumeration Date: 03/14/2022
Last Update Date: 03/11/2025
Certification Date: 03/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1605 MARTIN SPRINGS DR STE 230
ROLLA MO
65401-2980
US

IV. Provider business mailing address

455 COUNTY ROAD 856
BUNKER MO
63629-8150
US

V. Phone/Fax

Practice location:
  • Phone: 573-458-6326
  • Fax:
Mailing address:
  • Phone: 573-604-2214
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2005028029
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: