Provider Demographics
NPI:1528601127
Name:GOSNELL, MICHELLE L (RN)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:L
Last Name:GOSNELL
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1674 HILDA DR
Mailing Address - Street 2:
Mailing Address - City:SANDWICH
Mailing Address - State:IL
Mailing Address - Zip Code:60548-9394
Mailing Address - Country:US
Mailing Address - Phone:847-738-6511
Mailing Address - Fax:
Practice Address - Street 1:1850 GATEWAY DR
Practice Address - Street 2:
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178-3192
Practice Address - Country:US
Practice Address - Phone:815-758-8671
Practice Address - Fax:815-758-5491
Is Sole Proprietor?:No
Enumeration Date:2019-10-26
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209020890363LP0808X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health