Provider Demographics
NPI:1659688687
Name:RICHARDSON, MICHELLE RENEE (FNP)
Entity Type:Individual
Prefix:MISS
First Name:MICHELLE
Middle Name:RENEE
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4801 N CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60630-3211
Mailing Address - Country:US
Mailing Address - Phone:866-389-2727
Mailing Address - Fax:401-652-9787
Practice Address - Street 1:4801 N CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60630-3211
Practice Address - Country:US
Practice Address - Phone:866-389-2727
Practice Address - Fax:401-652-9787
Is Sole Proprietor?:No
Enumeration Date:2010-09-13
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209008301363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily