Provider Demographics
NPI:1134480379
Name:PEVONKA-THOMPSON, MICHELLE A (BSN, RN)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:A
Last Name:PEVONKA-THOMPSON
Suffix:
Gender:F
Credentials:BSN, RN
Other - Prefix:
Other - First Name:HAPPY FEET AT HOME
Other - Middle Name:FEET AT HOME,
Other - Last Name:LLC
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:BSN, RN
Mailing Address - Street 1:128 NORTHBREEZE DR
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-1225
Mailing Address - Country:US
Mailing Address - Phone:920-944-4443
Mailing Address - Fax:920-968-7707
Practice Address - Street 1:128 NORTHBREEZE DR
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-1225
Practice Address - Country:US
Practice Address - Phone:920-944-4443
Practice Address - Fax:920-968-7707
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-05
Last Update Date:2017-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI123478-30163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health