Provider Demographics
NPI:1265777163
Name:MINUTOLO, MICHELLE NICOLE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:NICOLE
Last Name:MINUTOLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3057 STATE ROUTE 88 N APT 2
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NY
Mailing Address - Zip Code:14513-9316
Mailing Address - Country:US
Mailing Address - Phone:315-573-3244
Mailing Address - Fax:
Practice Address - Street 1:3057 STATE ROUTE 88 N APT 2
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NY
Practice Address - Zip Code:14513-9316
Practice Address - Country:US
Practice Address - Phone:315-573-3244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-03
Last Update Date:2012-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY303680164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse