Provider Demographics
NPI:1376026716
Name:DORN, MICHELLE L (CPNP-PC)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:L
Last Name:DORN
Suffix:
Gender:F
Credentials:CPNP-PC
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:R
Other - Last Name:LAWSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:3959 BROADWAY FL 2
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-1559
Mailing Address - Country:US
Mailing Address - Phone:212-305-4436
Mailing Address - Fax:212-342-1443
Practice Address - Street 1:3959 BROADWAY FL 2
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-1559
Practice Address - Country:US
Practice Address - Phone:212-305-4436
Practice Address - Fax:212-342-1443
Is Sole Proprietor?:No
Enumeration Date:2018-09-12
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY382881363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics