Provider Demographics
NPI:1699209387
Name:FISHER, MICHELLE M
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:M
Last Name:FISHER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2128 MAIN RD
Mailing Address - Street 2:APT 1
Mailing Address - City:CORFU
Mailing Address - State:NY
Mailing Address - Zip Code:14036-9650
Mailing Address - Country:US
Mailing Address - Phone:585-356-6934
Mailing Address - Fax:
Practice Address - Street 1:2128 MAIN RD
Practice Address - Street 2:APT 1
Practice Address - City:CORFU
Practice Address - State:NY
Practice Address - Zip Code:14036-9650
Practice Address - Country:US
Practice Address - Phone:585-356-6934
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-19
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3285121164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYAY89791TMedicaid