Provider Demographics
NPI:1558678953
Name:VILLANUEVA, MICHELLE
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:
Last Name:VILLANUEVA
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:DIMATULAC
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:19 QUAKER ST
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11040-1314
Mailing Address - Country:US
Mailing Address - Phone:516-582-8504
Mailing Address - Fax:
Practice Address - Street 1:19 QUAKER ST
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11040-1314
Practice Address - Country:US
Practice Address - Phone:516-582-8504
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-07
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY4957081367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered