Provider Demographics
NPI:1003841206
Name:REGAN, MICHELLE LEIGH (PPCNP-BC)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LEIGH
Last Name:REGAN
Suffix:
Gender:F
Credentials:PPCNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1615 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:BALDWIN
Mailing Address - State:MI
Mailing Address - Zip Code:49304-7984
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:95 E 120TH ST
Practice Address - Street 2:
Practice Address - City:GRANT
Practice Address - State:MI
Practice Address - Zip Code:49327-8623
Practice Address - Country:US
Practice Address - Phone:231-834-1350
Practice Address - Fax:231-834-1355
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704200949363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4749993Medicaid