Provider Demographics
NPI:1265013312
Name:TAVARES, MICHELLE (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:TAVARES
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 EVERTS AVE
Mailing Address - Street 2:
Mailing Address - City:GLENS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12804-2040
Mailing Address - Country:US
Mailing Address - Phone:518-793-4700
Mailing Address - Fax:518-793-6325
Practice Address - Street 1:37 EVERTS AVE
Practice Address - Street 2:
Practice Address - City:GLENS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12804-2040
Practice Address - Country:US
Practice Address - Phone:518-793-4700
Practice Address - Fax:518-793-6325
Is Sole Proprietor?:No
Enumeration Date:2021-04-20
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY405859363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health