Healthcare Provider Details

I. General information

NPI: 1073442596
Provider Name (Legal Business Name): MRS. MICHELLE GILLEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2026
Last Update Date: 05/19/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5616 L ST
OMAHA NE
68117-1333
US

IV. Provider business mailing address

5616 L ST
OMAHA NE
68117-1333
US

V. Phone/Fax

Practice location:
  • Phone: 531-299-2900
  • Fax:
Mailing address:
  • Phone: 531-299-2900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374700000X
TaxonomyTechnician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: