Provider Demographics
NPI:1982375523
Name:KENTFIELD, MICHELLE DIANNE (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:DIANNE
Last Name:KENTFIELD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16003 MIDDLE ISLAND DRIVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:NE
Mailing Address - Zip Code:68058
Mailing Address - Country:US
Mailing Address - Phone:402-430-8728
Mailing Address - Fax:
Practice Address - Street 1:11810 NICHOLAS ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68154-4449
Practice Address - Country:US
Practice Address - Phone:402-779-8400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-23
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical