Provider Demographics
NPI:1376279729
Name:MOUNTFORT, MICHELLE R (RN)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:R
Last Name:MOUNTFORT
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:RENEE
Other - Last Name:BURKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:720 BAY RD
Mailing Address - Street 2:
Mailing Address - City:MENLO PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94025-1608
Mailing Address - Country:US
Mailing Address - Phone:970-261-9445
Mailing Address - Fax:
Practice Address - Street 1:3801 MIRANDA AVE
Practice Address - Street 2:
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94304-1290
Practice Address - Country:US
Practice Address - Phone:650-333-5148
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-28
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORN.0129023163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse