Provider Demographics
NPI:1013491059
Name:VAN EWYK, MICHELLE LEE (APRN)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LEE
Last Name:VAN EWYK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:473 W ARMY TRAIL RD STE 103
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60108-2674
Mailing Address - Country:US
Mailing Address - Phone:630-529-6969
Mailing Address - Fax:630-529-5993
Practice Address - Street 1:473 W ARMY TRAIL RD STE 103
Practice Address - Street 2:
Practice Address - City:BLOOMINGDALE
Practice Address - State:IL
Practice Address - Zip Code:60108-2674
Practice Address - Country:US
Practice Address - Phone:630-529-6969
Practice Address - Fax:630-529-5993
Is Sole Proprietor?:No
Enumeration Date:2018-09-15
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.412825163W00000X
IL209.018061363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163W00000XNursing Service ProvidersRegistered Nurse