Provider Demographics
NPI:1659604320
Name:MEDEIROS, MICHELLE E (NP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:E
Last Name:MEDEIROS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:E
Other - Last Name:MONGEAU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:45 RESNIK RD
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02360-4844
Mailing Address - Country:US
Mailing Address - Phone:508-746-0754
Mailing Address - Fax:508-747-7867
Practice Address - Street 1:45 RESNIK RD
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360-4844
Practice Address - Country:US
Practice Address - Phone:508-746-0754
Practice Address - Fax:508-747-7867
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-14
Last Update Date:2013-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA279163363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health