Provider Demographics
NPI:1205011467
Name:JORSTAD, MICHELE LYNN (APRN)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:LYNN
Last Name:JORSTAD
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 37189
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21297-3189
Mailing Address - Country:US
Mailing Address - Phone:571-423-5699
Mailing Address - Fax:571-423-5698
Practice Address - Street 1:3833 FAIRFAX DR
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22203-1772
Practice Address - Country:US
Practice Address - Phone:571-405-2822
Practice Address - Fax:571-748-4257
Is Sole Proprietor?:No
Enumeration Date:2008-01-07
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP129007363LF0000X
VA0024176620363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS500001719Medicare PIN
MSQ36090Medicare UPIN
MS04980042Medicaid