Provider Demographics
NPI:1821228149
Name:DU LAC, MICHELLE K (IDMT)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:K
Last Name:DU LAC
Suffix:
Gender:F
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 MAGNOLIA AVE
Mailing Address - Street 2:
Mailing Address - City:SHALIMAR
Mailing Address - State:FL
Mailing Address - Zip Code:32579-1110
Mailing Address - Country:US
Mailing Address - Phone:850-881-2198
Mailing Address - Fax:
Practice Address - Street 1:113 LIELMANIS AVE
Practice Address - Street 2:
Practice Address - City:HURLBURT FIELD
Practice Address - State:FL
Practice Address - Zip Code:32544-5613
Practice Address - Country:US
Practice Address - Phone:850-881-2198
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-21
Last Update Date:2009-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians