Provider Demographics
NPI:1063490134
Name:LAVELLE-HENRY, MICHELLE MADELINE (NP)
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:MADELINE
Last Name:LAVELLE-HENRY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:HENRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ANCC
Mailing Address - Street 1:6521 MCCAULEY
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55439-1028
Mailing Address - Country:US
Mailing Address - Phone:952-942-7569
Mailing Address - Fax:612-273-9945
Practice Address - Street 1:6521 MCCAULEY
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55439-1028
Practice Address - Country:US
Practice Address - Phone:952-942-7569
Practice Address - Fax:612-273-9945
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2012-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR953047363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN50BBHKWMedicare UPIN