Provider Demographics
NPI:1043820251
Name:ADDISON, MICHELLE KATHERINE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:KATHERINE
Last Name:ADDISON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:KATHERINE
Other - Last Name:HICZUN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:109 ARMSTRONG AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14617-4603
Mailing Address - Country:US
Mailing Address - Phone:716-957-8537
Mailing Address - Fax:
Practice Address - Street 1:20 HAGEN DR STE 330
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14625-2664
Practice Address - Country:US
Practice Address - Phone:585-267-4040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-03
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY346255363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily