Provider Demographics
NPI:1871040923
Name:LITTLE, MICHELLE D (APN)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:D
Last Name:LITTLE
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:D
Other - Last Name:LAWSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APN
Mailing Address - Street 1:8600 STATE ROUTE 91 STE 130
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-7829
Mailing Address - Country:US
Mailing Address - Phone:309-683-5050
Mailing Address - Fax:
Practice Address - Street 1:8600 STATE ROUTE 91 STE 130
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-7829
Practice Address - Country:US
Practice Address - Phone:309-683-5050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-07
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-014813363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner