Provider Demographics
NPI:1457540379
Name:SANDINE, MICHELLE MARIE (APN)
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:MARIE
Last Name:SANDINE
Suffix:
Gender:F
Credentials:APN
Other - Prefix:MS
Other - First Name:MICHELLE
Other - Middle Name:MARIE
Other - Last Name:NICE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APN
Mailing Address - Street 1:535 ROXBURY RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-5076
Mailing Address - Country:US
Mailing Address - Phone:815-387-1717
Mailing Address - Fax:
Practice Address - Street 1:535 ROXBURY RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-5076
Practice Address - Country:US
Practice Address - Phone:815-387-1717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-16
Last Update Date:2015-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.006739041.248938363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily