Provider Demographics
NPI:1376846337
Name:VAN DE WALL, MICHELLE J (APRN)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:J
Last Name:VAN DE WALL
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:JAMES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:781 CYPRESS VILLAGE BLVD
Mailing Address - Street 2:
Mailing Address - City:SUN CITY CENTER
Mailing Address - State:FL
Mailing Address - Zip Code:33573-6801
Mailing Address - Country:US
Mailing Address - Phone:727-824-0780
Mailing Address - Fax:727-568-6011
Practice Address - Street 1:781 CYPRESS VILLAGE BLVD
Practice Address - Street 2:
Practice Address - City:SUN CITY CENTER
Practice Address - State:FL
Practice Address - Zip Code:33573-6801
Practice Address - Country:US
Practice Address - Phone:727-824-0780
Practice Address - Fax:727-568-6011
Is Sole Proprietor?:No
Enumeration Date:2010-12-14
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9165034363LA2200X
FLARNP9165034363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL008055400Medicaid