Provider Demographics
NPI:1043528953
Name:HALLSTROM, MICHELLE R (CRNP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:R
Last Name:HALLSTROM
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:89 BEAVER DR
Mailing Address - Street 2:
Mailing Address - City:DU BOIS
Mailing Address - State:PA
Mailing Address - Zip Code:15801-2425
Mailing Address - Country:US
Mailing Address - Phone:814-371-4524
Mailing Address - Fax:814-371-0331
Practice Address - Street 1:89 BEAVER DR
Practice Address - Street 2:
Practice Address - City:DU BOIS
Practice Address - State:PA
Practice Address - Zip Code:15801-2425
Practice Address - Country:US
Practice Address - Phone:814-371-4524
Practice Address - Fax:814-371-0331
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-14
Last Update Date:2010-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP010892363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner