Provider Demographics
NPI:1881035632
Name:FUNK, MICHELLE (RN)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:FUNK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:913 S WESTHILL CT
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-2119
Mailing Address - Country:US
Mailing Address - Phone:812-336-8121
Mailing Address - Fax:
Practice Address - Street 1:913 S WESTHILL CT
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-2119
Practice Address - Country:US
Practice Address - Phone:812-336-8121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-09
Last Update Date:2013-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28169537A163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN28169537AOtherINDIANA STATE BOARD OF NURSING LICENSE