Provider Demographics
NPI:1023668092
Name:MOTTERN, MICHELLE R (APRN)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:R
Last Name:MOTTERN
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 1:106 GREGORY CIR
Mailing Address - Street 2:
Mailing Address - City:AUBURNDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33823-2320
Mailing Address - Country:US
Mailing Address - Phone:863-255-6449
Mailing Address - Fax:
Practice Address - Street 1:7225 N NEBRASKA AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33604-4916
Practice Address - Country:US
Practice Address - Phone:813-236-1182
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-12
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20210310242084A0401X
FL11002262207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine