Provider Demographics
NPI:1629854906
Name:CROUGH, MICHELLE RAE (CMA)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RAE
Last Name:CROUGH
Suffix:
Gender:F
Credentials:CMA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 19TH ST NE
Mailing Address - Street 2:
Mailing Address - City:DEVILS LAKE
Mailing Address - State:ND
Mailing Address - Zip Code:58301-1614
Mailing Address - Country:US
Mailing Address - Phone:701-351-0147
Mailing Address - Fax:
Practice Address - Street 1:104 19TH ST NE
Practice Address - Street 2:
Practice Address - City:DEVILS LAKE
Practice Address - State:ND
Practice Address - Zip Code:58301-1614
Practice Address - Country:US
Practice Address - Phone:701-351-0147
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-04
Last Update Date:2023-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND45819310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility