Basic Information
| Provider Information | |||||||||
| NPI: | 1033243209 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROTTNER | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | FNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ROARK | ||||||||
| OtherFirstName: | MICHELLE | ||||||||
| OtherMiddleName: | LYNN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1600 HIGHWAY 17 N | ||||||||
| Address2: | |||||||||
| City: | SURFSIDE BEACH | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295756015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436528226 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1600 HIGHWAY 17 N | ||||||||
| Address2: | |||||||||
| City: | SURFSIDE BEACH | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295756015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8432381461 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2007 | ||||||||
| LastUpdateDate: | 07/12/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 71002798A | IN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | ARNP 9371635 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 209-001576 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 21514 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 200976670 | 05 | IN | MEDICAID | 000000796630 | 01 | IN | BCBS | OTHER | YON25 | 01 | FL | BCBSFL | OTHER |