Provider Demographics
NPI:1235695313
Name:DIXON, MICHELE LOUISE (CRNA)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:LOUISE
Last Name:DIXON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15027 ELLEN DR
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48154-5148
Mailing Address - Country:US
Mailing Address - Phone:734-674-7580
Mailing Address - Fax:
Practice Address - Street 1:8140 N MOPAC EXPY STE 3-210
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-8862
Practice Address - Country:US
Practice Address - Phone:512-493-9237
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-14
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704306656367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
000OtherN/A