Provider Demographics
NPI:1932532256
Name:CHURCHILL, MICHELLE LYNN (APN)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LYNN
Last Name:CHURCHILL
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:LYNN
Other - Last Name:YOUNG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 64474
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4474
Mailing Address - Country:US
Mailing Address - Phone:410-955-2097
Mailing Address - Fax:
Practice Address - Street 1:777 PARK AVE W
Practice Address - Street 2:
Practice Address - City:HIGHLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60035-2433
Practice Address - Country:US
Practice Address - Phone:847-432-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-11
Last Update Date:2016-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR213911363LA2200X
IL209.010477363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health