Provider Demographics
NPI:1558398057
Name:WIDECAN, MICHELLE L (CNP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:L
Last Name:WIDECAN
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3333 BURNET AVE
Mailing Address - Street 2:ML 2008
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45229-3026
Mailing Address - Country:US
Mailing Address - Phone:513-636-7966
Mailing Address - Fax:513-636-7967
Practice Address - Street 1:3333 BURNET AVE
Practice Address - Street 2:ML 2008
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45229-3026
Practice Address - Country:US
Practice Address - Phone:513-636-7966
Practice Address - Fax:513-636-7967
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2017-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.06775-NP363LP0200X
OHAPRN.CNP.06775363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics