Provider Demographics
NPI:1114675501
Name:BLAND, MICHELLE LYNN (APRN, FNP-C)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LYNN
Last Name:BLAND
Suffix:
Gender:F
Credentials:APRN, FNP-C
Other - Prefix:
Other - First Name:SHELLEY
Other - Middle Name:LYNN
Other - Last Name:BLAND
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:APRN, FNP-C
Mailing Address - Street 1:455 COUNTY ROAD 856
Mailing Address - Street 2:
Mailing Address - City:BUNKER
Mailing Address - State:MO
Mailing Address - Zip Code:63629-8150
Mailing Address - Country:US
Mailing Address - Phone:573-604-2214
Mailing Address - Fax:
Practice Address - Street 1:35629 HIGHWAY 72
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:MO
Practice Address - Zip Code:65560-7217
Practice Address - Country:US
Practice Address - Phone:573-729-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-14
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005028029363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty