Provider Demographics
NPI:1366835779
Name:VAN ERT, MICHELLE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:VAN ERT
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 1:900 E RIVERVIEW EXPY
Mailing Address - Street 2:
Mailing Address - City:WISCONSIN RAPIDS
Mailing Address - State:WI
Mailing Address - Zip Code:54494-5482
Mailing Address - Country:US
Mailing Address - Phone:715-423-2585
Mailing Address - Fax:
Practice Address - Street 1:900 E RIVERVIEW EXPY
Practice Address - Street 2:
Practice Address - City:WISCONSIN RAPIDS
Practice Address - State:WI
Practice Address - Zip Code:54494-5482
Practice Address - Country:US
Practice Address - Phone:715-423-2585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-09
Last Update Date:2015-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17074-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist