Provider Demographics
NPI:1760653836
Name:LAMENDOLA, MICHELLE R (ANP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:R
Last Name:LAMENDOLA
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4350 N 19TH AVE
Mailing Address - Street 2:SUITE 6
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85015-4602
Mailing Address - Country:US
Mailing Address - Phone:602-264-9191
Mailing Address - Fax:602-532-2973
Practice Address - Street 1:4350 N 19TH AVE STE 6
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-4697
Practice Address - Country:US
Practice Address - Phone:602-264-9191
Practice Address - Fax:602-532-2973
Is Sole Proprietor?:No
Enumeration Date:2008-03-17
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP7225363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ477621Medicaid
AZ477621Medicaid