Provider Demographics
NPI:1598907545
Name:MOLDREM, MICHELE D (MHNP)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:D
Last Name:MOLDREM
Suffix:
Gender:F
Credentials:MHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:988 N ILLINOIS ROUTE 3
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IL
Mailing Address - Zip Code:62298-1059
Mailing Address - Country:US
Mailing Address - Phone:618-939-4444
Mailing Address - Fax:
Practice Address - Street 1:988 N ILLINOIS ROUTE 3
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IL
Practice Address - Zip Code:62298
Practice Address - Country:US
Practice Address - Phone:619-393-4444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-06
Last Update Date:2018-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9265071363LP0808X
IL209018106363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health