Provider Demographics
NPI:1508873415
Name:MIKE-NICHOLS, MICHELLE MARIE (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:MARIE
Last Name:MIKE-NICHOLS
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E LIBERTY ST
Mailing Address - Street 2:SUITE 800
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1434
Mailing Address - Country:US
Mailing Address - Phone:502-587-6010
Mailing Address - Fax:502-587-1314
Practice Address - Street 1:6400 DUTCHMANS PKWY STE 345
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40205-3370
Practice Address - Country:US
Practice Address - Phone:502-587-6010
Practice Address - Fax:502-587-1314
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3626P363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1059305OtherPASSPORT
KY65922213Medicaid
KY65922213Medicaid
KYK163390Medicare PIN
KY2590Medicare PIN