Provider Demographics
NPI:1336119809
Name:JUSTUS, MICHELLE K (NP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:K
Last Name:JUSTUS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:K
Other - Last Name:JEPSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:5629 STADIUM DR
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-1952
Mailing Address - Country:US
Mailing Address - Phone:269-372-1000
Mailing Address - Fax:269-372-0698
Practice Address - Street 1:5629 STADIUM DR
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-1952
Practice Address - Country:US
Practice Address - Phone:269-372-1000
Practice Address - Fax:269-372-0698
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2021-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704195306363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4486060Medicaid
MIM97850006Medicare PIN