Basic Information
| Provider Information | |||||||||
| NPI: | 1285604421 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DODDS | ||||||||
| FirstName: | MICHELE | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | FNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 5400 DUPONT CIR | ||||||||
| Address2: | SUITE A | ||||||||
| City: | MILFORD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 451502793 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135767700 | ||||||||
| FaxNumber: | 5135761020 | ||||||||
| Practice Location | |||||||||
| Address1: | 536 MIRABEAU ST | ||||||||
| Address2: | |||||||||
| City: | GREENFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 451231457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9379819444 | ||||||||
| FaxNumber: | 9379819448 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2006 | ||||||||
| LastUpdateDate: | 04/18/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | RN255122 NP06603 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 2324489 | 05 | OH | MEDICAID |