Provider Demographics
NPI:1811042914
Name:PIPKE, MICHELLE R (BS P T)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:R
Last Name:PIPKE
Suffix:
Gender:F
Credentials:BS P T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3637 W CHARLESTON AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-2808
Mailing Address - Country:US
Mailing Address - Phone:602-561-5213
Mailing Address - Fax:
Practice Address - Street 1:17999 W. SURPRISE FARMS LOOP SOUTH
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85388
Practice Address - Country:US
Practice Address - Phone:623-876-7388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2536174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ2536OtherPT LICENSE NUMBER