Provider Demographics
NPI:1982655213
Name:PARADIS, MICHELE GLORIA (APRN BC)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:GLORIA
Last Name:PARADIS
Suffix:
Gender:F
Credentials:APRN BC
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:RAPHAEL
Other - Last Name:PARADIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:APRN BC
Mailing Address - Street 1:803 4TH ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MN
Mailing Address - Zip Code:56143-1056
Mailing Address - Country:US
Mailing Address - Phone:507-847-3571
Mailing Address - Fax:507-847-5664
Practice Address - Street 1:803 4TH ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MN
Practice Address - Zip Code:56143-1056
Practice Address - Country:US
Practice Address - Phone:507-847-3571
Practice Address - Fax:507-847-5664
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704155091363LP0808X
MN121976-4163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5008754170OtherBCBS
MI114832525Medicaid
MI5008754170OtherBCBS