Provider Demographics
NPI:1205828654
Name:MICHAELSON, GLADYS BETH (APNP)
Entity Type:Individual
Prefix:MRS
First Name:GLADYS
Middle Name:BETH
Last Name:MICHAELSON
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:MISS
Other - First Name:GLADYS
Other - Middle Name:BETH
Other - Last Name:DURST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1506 S ONEIDA ST
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54915-1305
Mailing Address - Country:US
Mailing Address - Phone:920-730-6700
Mailing Address - Fax:920-730-2615
Practice Address - Street 1:1506 S ONEIDA ST
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54915-1305
Practice Address - Country:US
Practice Address - Phone:920-730-6700
Practice Address - Fax:920-730-2615
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI102011363LA2200X
WI102011-030163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43977600Medicaid
WIP73252Medicare UPIN
WI43977600Medicaid
WI0038Medicare PIN