Provider Demographics
NPI:1467108373
Name:CHURCH, MICHELLE (CRNP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:CHURCH
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1525 TAMIAMI TRL S
Mailing Address - Street 2:STE 603F
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34285-3568
Mailing Address - Country:US
Mailing Address - Phone:941-275-2968
Mailing Address - Fax:941-480-1033
Practice Address - Street 1:700 W GROVE ST
Practice Address - Street 2:
Practice Address - City:CLARKS SUMMIT
Practice Address - State:PA
Practice Address - Zip Code:18411-2032
Practice Address - Country:US
Practice Address - Phone:570-350-2845
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-01
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP025189363LP0808X
FL11017558363LC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LC1500XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCommunity Health
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health