Provider Demographics
NPI:1306370721
Name:KRETZSCHMAR, MICHELLE D (RN, AE-C)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:D
Last Name:KRETZSCHMAR
Suffix:
Gender:F
Credentials:RN, AE-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 N KEENE ST
Mailing Address - Street 2:SUITE 115
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-6626
Mailing Address - Country:US
Mailing Address - Phone:573-884-8190
Mailing Address - Fax:573-884-3991
Practice Address - Street 1:404 N KEENE ST
Practice Address - Street 2:SUITE 115
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-6626
Practice Address - Country:US
Practice Address - Phone:573-884-8190
Practice Address - Fax:573-884-3991
Is Sole Proprietor?:No
Enumeration Date:2017-04-12
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO127917163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO35AEMedicaid