Provider Demographics
NPI:1003212176
Name:CUNNINGHAM, MICHELLE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:CUNNINGHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8990 SPRINGBROOK DR NW
Mailing Address - Street 2:SUITE 250
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-5850
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8650 HUDSON BLVD N
Practice Address - Street 2:SUITE 235
Practice Address - City:LAKE ELMO
Practice Address - State:MN
Practice Address - Zip Code:55042-9747
Practice Address - Country:US
Practice Address - Phone:651-702-7400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-17
Last Update Date:2014-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 179219-7367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered