MEDICARE: MICHELLE ANN NISSEN AG-ACNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LA2100X	Acute Care Nurse Practitioner	COA.17492-NP	OH

General Provider Information

NPI Number	:	1346622578
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELLE ANN NISSEN AG-ACNP

Provider Business Mailing Address
First Line	:	1530 NEEDMORE RD STE 300
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45414-3980
Country	:	US
Telephone Number	:	937-277-4274
Fax Number	:	937-277-8476

Provider Business Practice Location Address
First Line	:	1530 NEEDMORE RD STE 300
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45414-3980
Country	:	US
Telephone Number	:	937-277-4274
Fax Number	:	937-277-8476

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/24/2015
Last Update Date	:	07/15/2015

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