Provider Demographics
NPI:1003283920
Name:BANDY, MICHELLE (LPN)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:BANDY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1999 WABASH AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-5351
Mailing Address - Country:US
Mailing Address - Phone:217-523-2273
Mailing Address - Fax:217-523-2272
Practice Address - Street 1:1999 WABASH AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-5351
Practice Address - Country:US
Practice Address - Phone:217-523-2273
Practice Address - Fax:217-523-2272
Is Sole Proprietor?:No
Enumeration Date:2015-08-26
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043.083129164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse