Provider Demographics
NPI:1467749184
Name:GAVIN, MICHELLE M (GNP, BC)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:M
Last Name:GAVIN
Suffix:
Gender:F
Credentials:GNP, BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1836 SOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-5429
Mailing Address - Country:US
Mailing Address - Phone:608-782-7300
Mailing Address - Fax:
Practice Address - Street 1:505 GOPHER DR
Practice Address - Street 2:
Practice Address - City:TOMAH
Practice Address - State:WI
Practice Address - Zip Code:54660-4513
Practice Address - Country:US
Practice Address - Phone:608-372-4111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-01
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2057363LN0000X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal