Provider Demographics
NPI:1396730073
Name:TEGENKAMP, MICHELLE (RN,CPNP)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:TEGENKAMP
Suffix:
Gender:F
Credentials:RN,CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 BELLEFONTAINE AVE
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45804-2800
Mailing Address - Country:US
Mailing Address - Phone:419-998-4575
Mailing Address - Fax:419-998-4586
Practice Address - Street 1:1005 BELLEFONTAINE AVE STE 245
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45804-2884
Practice Address - Country:US
Practice Address - Phone:419-998-8230
Practice Address - Fax:419-998-8231
Is Sole Proprietor?:No
Enumeration Date:2005-09-19
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH20030435363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2456060Medicaid