Provider Demographics
NPI:1245840081
Name:MICHAUD, ANNALISE KATHLEEN (MSN, PMHNP-BC)
Entity type:Individual
Prefix:
First Name:ANNALISE
Middle Name:KATHLEEN
Last Name:MICHAUD
Suffix:
Gender:F
Credentials:MSN, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 N BRADNER AVE
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952-2449
Mailing Address - Country:US
Mailing Address - Phone:765-664-8000
Mailing Address - Fax:877-731-2066
Practice Address - Street 1:515 N BRADNER AVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46952-2449
Practice Address - Country:US
Practice Address - Phone:765-664-8000
Practice Address - Fax:877-731-2066
Is Sole Proprietor?:No
Enumeration Date:2020-08-06
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71010241A363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN71010241AOtherAPRN PRESCRIPTIVE AUTHORITY
IN71010241BOtherCSR- PRESCRIPTIVE AUTHORITY