MEDICARE: MICHELLE DIANNE KENTFIELD PA-C

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	363AM0700X	Medical Physician Assistant		NE

General Provider Information

NPI Number	:	1982375523
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELLE DIANNE KENTFIELD PA-C

Provider Business Mailing Address
First Line	:	16003 MIDDLE ISLAND DRIVE
Second Line	:
City	:	SOUTH BEND
State	:	NE
Zip	:	68058
Country	:	US
Telephone Number	:	402-430-8728
Fax Number	:

Provider Business Practice Location Address
First Line	:	11810 NICHOLAS ST
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68154-4449
Country	:	US
Telephone Number	:	402-779-8400
Fax Number	:

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

Provider Enumeration Date	:	09/23/2021
Last Update Date	:	10/30/2023

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