Provider Demographics
NPI:1629342639
Name:DACEY-NEWMAN, MICHELLE MARIE (LPN)
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:MARIE
Last Name:DACEY-NEWMAN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MS
Other - First Name:MICHELLE
Other - Middle Name:MARIE
Other - Last Name:DACEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:505 13TH ST
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53140-4432
Mailing Address - Country:US
Mailing Address - Phone:262-220-1141
Mailing Address - Fax:
Practice Address - Street 1:3010 GRAND AVE
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085-2321
Practice Address - Country:US
Practice Address - Phone:847-377-8296
Practice Address - Fax:847-984-5689
Is Sole Proprietor?:No
Enumeration Date:2012-03-08
Last Update Date:2012-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043087431164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL043087431OtherILLINOIS DEPARTMENT OF PROFESSIONAL REGULATIONS