1689804296 NPI number — MICHELE DEVINE WALDEN APRN

Table of content: MICHELE DEVINE WALDEN APRN (NPI 1689804296)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689804296 NPI number — MICHELE DEVINE WALDEN APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALDEN
Provider First Name:
MICHELE
Provider Middle Name:
DEVINE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APRN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1689804296
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/28/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 776351
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60677-6351
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-588-9490
Provider Business Mailing Address Fax Number:
502-272-5116

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4123 DUTCHMANS LN
Provider Second Line Business Practice Location Address:
SUITE 503
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40207-4707
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-409-5600
Provider Business Practice Location Address Fax Number:
502-259-3078
Provider Enumeration Date:
07/16/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  3005978 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0808X , with the licence number: 3005978 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7100222320 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: K025250 . This is a "MEDICARE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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