Provider Demographics
NPI:1629165014
Name:MENKE, MICHAEL PHILIP (RN)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:PHILIP
Last Name:MENKE
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 OAKVIEW TER
Mailing Address - Street 2:#2
Mailing Address - City:JAMAICA PLAIN
Mailing Address - State:MA
Mailing Address - Zip Code:02130-4902
Mailing Address - Country:US
Mailing Address - Phone:617-522-5759
Mailing Address - Fax:
Practice Address - Street 1:415 COLUMBIA RD
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02125-2424
Practice Address - Country:US
Practice Address - Phone:617-740-8184
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA169059163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health