Provider Demographics
NPI:1083814958
Name:HOLMES, MICHELLE L (RN, CNP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:L
Last Name:HOLMES
Suffix:
Gender:F
Credentials:RN, CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1502 LONDON RD STE 102
Mailing Address - Street 2:ESSENTIA HEALTH LAKEWALK CLINIC
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55812-1787
Mailing Address - Country:US
Mailing Address - Phone:218-576-0100
Mailing Address - Fax:218-576-0126
Practice Address - Street 1:1502 LONDON RD STE 102
Practice Address - Street 2:ESSENTIA HEALTH LAKEWALK CLINIC
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55812-1787
Practice Address - Country:US
Practice Address - Phone:218-576-0100
Practice Address - Fax:218-576-0126
Is Sole Proprietor?:No
Enumeration Date:2007-07-19
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR131623-0363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1083814958Medicaid
MI1083814958Medicaid
WI1083814958Medicaid
MN1083814958Medicaid
MN500006696Medicare PIN