Basic Information
| Provider Information | |||||||||
| NPI: | 1023668092 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOTTERN | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 106 GREGORY CIR | ||||||||
| Address2: | |||||||||
| City: | AUBURNDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338232320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8632556449 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7225 N NEBRASKA AVE | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336044916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8132361182 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2019 | ||||||||
| LastUpdateDate: | 09/14/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084A0401X | 2021031024 | FL | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Medicine | 207Q00000X | 11002262 | FL | N | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.