Provider Demographics
NPI:1083161517
Name:DVORAK, MICHELLE MARY
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MARY
Last Name:DVORAK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:MARY
Other - Last Name:DVORAK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN
Mailing Address - Street 1:811 MOUTAIN VIEW DRIVE
Mailing Address - Street 2:APT 107
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82716-2340
Mailing Address - Country:US
Mailing Address - Phone:307-660-1303
Mailing Address - Fax:307-257-2695
Practice Address - Street 1:811 MOUNTAIN VIEW DR
Practice Address - Street 2:APT 107
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82716-2352
Practice Address - Country:US
Practice Address - Phone:307-660-1303
Practice Address - Fax:307-257-2695
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY33371163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health