Provider Demographics
NPI:1457544975
Name:LANDIS, MICHELLE LYNN (MED, LAT, ATC)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LYNN
Last Name:LANDIS
Suffix:
Gender:F
Credentials:MED, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:INDIANA STATE UNIVERSITY
Mailing Address - Street 2:ATHLETIC TRAINING DEPARTMENT
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47809-0001
Mailing Address - Country:US
Mailing Address - Phone:812-237-4062
Mailing Address - Fax:812-237-9612
Practice Address - Street 1:INDIANA STATE UNIVERSITY
Practice Address - Street 2:ATHLETIC TRAINING DEPARTMENT
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47809-0001
Practice Address - Country:US
Practice Address - Phone:812-237-4062
Practice Address - Fax:812-237-9612
Is Sole Proprietor?:No
Enumeration Date:2007-08-20
Last Update Date:2007-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36001411A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer