Healthcare Provider Details

I. General information

NPI: 1316349665
Provider Name (Legal Business Name): JILL MICHALAK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2014
Last Update Date: 11/03/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5871 MONCLOVA RD
MAUMEE OH
43537-1839
US

IV. Provider business mailing address

5871 MONCLOVA RD
MAUMEE OH
43537-1839
US

V. Phone/Fax

Practice location:
  • Phone: 419-897-8376
  • Fax: 419-887-8789
Mailing address:
  • Phone: 198-978-3764
  • Fax: 419-887-8789

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License NumberRN249642
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCOA.15618-NP
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN.CNP.15618
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: