Provider Demographics
NPI:1649314220
Name:ANTHONY, MICHELLE DEZURA (NP)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:DEZURA
Last Name:ANTHONY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5125 SKYLINE RD S
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97306-9413
Mailing Address - Country:US
Mailing Address - Phone:503-315-4663
Mailing Address - Fax:
Practice Address - Street 1:5125 SKYLINE RD S
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97306-9427
Practice Address - Country:US
Practice Address - Phone:503-315-4663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN79000363LA2100X
LAAP04978363LA2100X
WAAP60436588363LA2200X
OR201392913NP-PP363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00754042Medicaid
LA1013889Medicaid
LA3A379Medicare PIN