Provider Demographics
NPI:1558667196
Name:PACK, MICHELLE ANN (LPN)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ANN
Last Name:PACK
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 LINTON RD
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:OH
Mailing Address - Zip Code:44047-8228
Mailing Address - Country:US
Mailing Address - Phone:440-969-4169
Mailing Address - Fax:
Practice Address - Street 1:2900 LINTON RD
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:OH
Practice Address - Zip Code:44047-8228
Practice Address - Country:US
Practice Address - Phone:440-969-4169
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-30
Last Update Date:2011-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH131726164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse