Basic Information
| Provider Information | |||||||||
| NPI: | 1184601841 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YATES | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | LEIGH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GREGG | ||||||||
| OtherFirstName: | MICHELLE | ||||||||
| OtherMiddleName: | LEIGH | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | NP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1848 | ||||||||
| Address2: | |||||||||
| City: | MUSKEGON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494431848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2317274444 | ||||||||
| FaxNumber: | 2317274451 | ||||||||
| Practice Location | |||||||||
| Address1: | 1150 E SHERMAN BLVD | ||||||||
| Address2: | SUITE 1125 | ||||||||
| City: | MUSKEGON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494441871 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2316726740 | ||||||||
| FaxNumber: | 2316726787 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/23/2005 | ||||||||
| LastUpdateDate: | 12/02/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 4704197487 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | N33890 | 01 | MI | MEDICARE GROUP PTAN | OTHER |