Provider Demographics
NPI:1649951617
Name:EVANS, MICHELLE ERIN
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ERIN
Last Name:EVANS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:ERIN
Other - Last Name:SCHNEIDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 778912
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-8912
Mailing Address - Country:US
Mailing Address - Phone:317-777-6435
Mailing Address - Fax:317-777-6644
Practice Address - Street 1:415 E COOK RD STE 300
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-3657
Practice Address - Country:US
Practice Address - Phone:317-948-7208
Practice Address - Fax:317-944-5791
Is Sole Proprietor?:No
Enumeration Date:2023-07-31
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28151551A363LP0200X
IN71015413A363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300092634Medicaid