Provider Demographics
NPI:1750695847
Name:GAUDIUSO, MICHELLE R (PNP)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:R
Last Name:GAUDIUSO
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:MISS
Other - First Name:MICHELLE
Other - Middle Name:R
Other - Last Name:SCAVONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2300 N CHILDRENS PLZ
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-3363
Mailing Address - Country:US
Mailing Address - Phone:773-327-3931
Mailing Address - Fax:
Practice Address - Street 1:2300 N CHILDRENS PLZ
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-3363
Practice Address - Country:US
Practice Address - Phone:773-327-3931
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-30
Last Update Date:2010-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.007811363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209.007811OtherSTATE LICENSE NUMBER