Provider Demographics
NPI:1699190751
Name:LU, MICHELLE ANN
Entity Type:Individual
Prefix:
First Name:MICHELLE ANN
Middle Name:
Last Name:LU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MICHELLE ANN
Other - Middle Name:SUAZO
Other - Last Name:GAMULO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NAR
Mailing Address - Street 1:11124 NE HALSEY ST # 572
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97220-2021
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11124 NE HALSEY ST # 572
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-2021
Practice Address - Country:US
Practice Address - Phone:888-354-2758
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-26
Last Update Date:2014-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WANAR.NA.60451427376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker