Provider Demographics
NPI:1558706614
Name:HEISLE, MICHELE NICOLE (LPN)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:NICOLE
Last Name:HEISLE
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 1:5205 SHASTA AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45417-9115
Mailing Address - Country:US
Mailing Address - Phone:937-397-0956
Mailing Address - Fax:
Practice Address - Street 1:5205 SHASTA AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45417-9115
Practice Address - Country:US
Practice Address - Phone:937-397-0956
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-02
Last Update Date:2013-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN152381164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse