Provider Demographics
NPI:1093014656
Name:SULTAGE, MICHELLE ELAINE (CRNP-FAMILY)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:ELAINE
Last Name:SULTAGE
Suffix:
Gender:F
Credentials:CRNP-FAMILY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28105 THREE NOTCH RD
Mailing Address - Street 2:1C
Mailing Address - City:MECHANICSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20659-3235
Mailing Address - Country:US
Mailing Address - Phone:301-290-1510
Mailing Address - Fax:
Practice Address - Street 1:28105 THREE NOTCH RD
Practice Address - Street 2:1C
Practice Address - City:MECHANICSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20659-3235
Practice Address - Country:US
Practice Address - Phone:301-290-1510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-22
Last Update Date:2015-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR161602363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily