Basic Information
Provider Information | |||||||||
NPI: | 1467409896 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TWOMBLY | ||||||||
FirstName: | MICHELLE | ||||||||
MiddleName: | LEE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6110 EMERALD LAKES DR | ||||||||
Address2: |   | ||||||||
City: | MEDINA | ||||||||
State: | OH | ||||||||
PostalCode: | 442567443 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3302414317 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3780 MEDINA RD | ||||||||
Address2: | SUITE 310 | ||||||||
City: | MEDINA | ||||||||
State: | OH | ||||||||
PostalCode: | 442565947 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3307258441 | ||||||||
FaxNumber: | 3307258442 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/30/2006 | ||||||||
LastUpdateDate: | 12/23/2010 | ||||||||
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 | 363LF0000X | NP-07063 | OH | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 2356123 | 05 | OH |   | MEDICAID |