Provider Demographics
NPI:1073295846
Name:STEVENS, MICHELLE DIANE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:DIANE
Last Name:STEVENS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76301-2219
Mailing Address - Country:US
Mailing Address - Phone:940-500-4903
Mailing Address - Fax:940-500-4906
Practice Address - Street 1:207 BROAD ST
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76301-2219
Practice Address - Country:US
Practice Address - Phone:940-500-4903
Practice Address - Fax:940-500-4906
Is Sole Proprietor?:No
Enumeration Date:2023-08-02
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX187071164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse