Provider Demographics
NPI:1881205359
Name:EICHENBERG, MICHELLE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:EICHENBERG
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 1:1028 EAST ST APT 8
Mailing Address - Street 2:
Mailing Address - City:FORT ATKINSON
Mailing Address - State:WI
Mailing Address - Zip Code:53538-2643
Mailing Address - Country:US
Mailing Address - Phone:920-568-1162
Mailing Address - Fax:
Practice Address - Street 1:1028 EAST ST APT 8
Practice Address - Street 2:
Practice Address - City:FORT ATKINSON
Practice Address - State:WI
Practice Address - Zip Code:53538-2643
Practice Address - Country:US
Practice Address - Phone:920-568-1162
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-10
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI318655164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse