Basic Information
| Provider Information | |||||||||
| NPI: | 1598860561 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MUELLER | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6333 SPARKS RD | ||||||||
| Address2: | P.O. BOX 882 | ||||||||
| City: | LAND O' LAKES | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7156175432 | ||||||||
| FaxNumber: | 7155452508 | ||||||||
| Practice Location | |||||||||
| Address1: | 2251 N SHORE DR | ||||||||
| Address2: | |||||||||
| City: | RHINELANDER | ||||||||
| State: | WI | ||||||||
| PostalCode: | 545016710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153612300 | ||||||||
| FaxNumber: | 7153612877 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2006 | ||||||||
| LastUpdateDate: | 11/23/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 591019 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
ID Information
| ID | Type | State | Issuer | Description | 40358800 | 05 | WI | MEDICAID |