Basic Information
| Provider Information | |||||||||
| NPI: | 1659642858 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MENKE | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | RENE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 825 S CABLE RD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458053467 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192241234 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 825 S CABLE RD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458053467 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192241234 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2012 | ||||||||
| LastUpdateDate: | 01/19/2012 | ||||||||
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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 | 363LF0000X | COA. 13042-NP | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.