Provider Demographics
NPI:1801868500
Name:KEROUAC, MICHELLE IRENE (RN)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:IRENE
Last Name:KEROUAC
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
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Mailing Address - Street 1:8810 RIO SAN DIEGO DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-1698
Mailing Address - Country:US
Mailing Address - Phone:858-784-1256
Mailing Address - Fax:
Practice Address - Street 1:34800 BOB WILSON DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134-1098
Practice Address - Country:US
Practice Address - Phone:619-532-9021
Practice Address - Fax:619-532-8598
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-06
Last Update Date:2020-04-21
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CA763720163W00000X
CA95001678363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse