Provider Demographics
NPI:1477099422
Name:FORD, MICHELLE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:FORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20769 E 13 MILE RD
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48066-4503
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20769 E 13 MILE RD
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-4503
Practice Address - Country:US
Practice Address - Phone:586-439-5088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-16
Last Update Date:2017-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704309683363LF0000X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse