Provider Demographics
NPI:1245721281
Name:MORTIMER, MICHELLE MAE (RN)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MAE
Last Name:MORTIMER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:MAE
Other - Last Name:EARLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PN, RN
Mailing Address - Street 1:PO BOX 130
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:VT
Mailing Address - Zip Code:05362-0130
Mailing Address - Country:US
Mailing Address - Phone:802-579-5138
Mailing Address - Fax:
Practice Address - Street 1:130 DUKE ROAD
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:VT
Practice Address - Zip Code:05362
Practice Address - Country:US
Practice Address - Phone:802-579-5138
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-25
Last Update Date:2018-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT026.0025732163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse