Provider Demographics
NPI:1902194996
Name:BLAIR-WUNDERLICH, MICHELLE RENEE (NP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RENEE
Last Name:BLAIR-WUNDERLICH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 W 8TH AVE
Mailing Address - Street 2:PO BOX 643
Mailing Address - City:WINFIELD
Mailing Address - State:KS
Mailing Address - Zip Code:67156-2718
Mailing Address - Country:US
Mailing Address - Phone:620-221-3350
Mailing Address - Fax:620-221-6061
Practice Address - Street 1:221 W 8TH AVE
Practice Address - Street 2:
Practice Address - City:WINFIELD
Practice Address - State:KS
Practice Address - Zip Code:67156-2718
Practice Address - Country:US
Practice Address - Phone:620-221-3350
Practice Address - Fax:620-221-6061
Is Sole Proprietor?:No
Enumeration Date:2011-07-12
Last Update Date:2012-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS53-75442-072363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner