Provider Demographics
NPI:1033243209
Name:ROTTNER, MICHELLE LYNN (FNP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LYNN
Last Name:ROTTNER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:LYNN
Other - Last Name:ROARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1600 HIGHWAY 17 N
Mailing Address - Street 2:
Mailing Address - City:SURFSIDE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29575-6015
Mailing Address - Country:US
Mailing Address - Phone:843-652-8226
Mailing Address - Fax:
Practice Address - Street 1:1600 HIGHWAY 17 N
Practice Address - Street 2:
Practice Address - City:SURFSIDE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29575-6015
Practice Address - Country:US
Practice Address - Phone:843-238-1461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71002798A363L00000X
FLARNP 9371635363LF0000X
IL209-001576363LF0000X
SC21514363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200976670Medicaid
IN000000796630OtherBCBS
FLYON25OtherBCBSFL
FLHW250ZMedicare PIN
FLYON25OtherBCBSFL