Provider Demographics
NPI:1649246091
Name:MERTENS-DODGEN, MICHELLE (ARNP)
Entity type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:
Last Name:MERTENS-DODGEN
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37822 US HIGHWAY 18
Mailing Address - Street 2:
Mailing Address - City:PRAIRIE DU CHIEN
Mailing Address - State:WI
Mailing Address - Zip Code:53821-8416
Mailing Address - Country:US
Mailing Address - Phone:608-357-2430
Mailing Address - Fax:
Practice Address - Street 1:37822 US HIGHWAY 18
Practice Address - Street 2:
Practice Address - City:PRAIRIE DU CHIEN
Practice Address - State:WI
Practice Address - Zip Code:53821-8416
Practice Address - Country:US
Practice Address - Phone:608-357-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209005481363L00000X
IAA-097512363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
90769OtherBCWELLMARK WEST
90770OtherBCWELLMARK 7TH
IL0181OtherJOHN DEERE
K16508Medicare ID - Type UnspecifiedINDIVIDUAL