=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467409896
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHELLE LEE TWOMBLY CNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/30/2006
-----------------------------------------------------
Last Update Date | 12/23/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3780 MEDINA RD SUITE 310
-----------------------------------------------------
City | MEDINA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44256-5947
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-725-8441
-----------------------------------------------------
Fax | 330-725-8442
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6110 EMERALD LAKES DR
-----------------------------------------------------
City | MEDINA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44256-7443
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-241-4317
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | NP-07063
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------