Provider Demographics
NPI:1053647248
Name:CANTWELL, MICHELLE LEIGH (FNP)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:LEIGH
Last Name:CANTWELL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:LEIGH
Other - Last Name:DEAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:8840 COMMERCE PARK PL STE E
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-3129
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7526 E 82ND ST STE 125
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-1467
Practice Address - Country:US
Practice Address - Phone:317-621-2121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-23
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN2009009290363LF0000X
IN71003113A363LF0000X
IN71003113AB363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201026110Medicaid
IN266180174Medicare PIN
IN28178416AOtherREGISTERED NURSE