Provider Demographics
NPI:1215603097
Name:REARDON, MICHELLE MARIE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MARIE
Last Name:REARDON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4201 SONOMA MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-8558
Mailing Address - Country:US
Mailing Address - Phone:707-540-5799
Mailing Address - Fax:
Practice Address - Street 1:2447 SUMMERFIELD RD
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-7815
Practice Address - Country:US
Practice Address - Phone:707-544-3299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-20
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program