Provider Demographics
NPI:1356414403
Name:FELLOWS, MICHELLE RENEE (LPN)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:RENEE
Last Name:FELLOWS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5405 STATE ROUTE 104
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13126-5803
Mailing Address - Country:US
Mailing Address - Phone:315-342-8460
Mailing Address - Fax:
Practice Address - Street 1:5405 STATE ROUTE 104
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:NY
Practice Address - Zip Code:13126-5803
Practice Address - Country:US
Practice Address - Phone:315-342-8460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY230286-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01763304Medicare ID - Type UnspecifiedPROVIDER ID