Provider Demographics
NPI:1619093366
Name:BANDURKA, MICHELLE M (CNP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:M
Last Name:BANDURKA
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 1:116 EAST AVE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:TALLMADGE
Mailing Address - State:OH
Mailing Address - Zip Code:44278-2300
Mailing Address - Country:US
Mailing Address - Phone:330-633-7782
Mailing Address - Fax:330-633-4701
Practice Address - Street 1:941 W MORSE BLVD STE 100
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-3781
Practice Address - Country:US
Practice Address - Phone:321-207-9029
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH11114-COA363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3012797Medicaid
OHH211570Medicare PIN