Basic Information
| Provider Information | |||||||||
| NPI: | 1679821862 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MICELI | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | M | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 16149 | ||||||||
| Address2: | |||||||||
| City: | RUMFORD | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029160697 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014539625 | ||||||||
| FaxNumber: | 4014357069 | ||||||||
| Practice Location | |||||||||
| Address1: | 593 EDDY STREET | ||||||||
| Address2: | APC 4 | ||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 02903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014444700 | ||||||||
| FaxNumber: | 4014446681 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2012 | ||||||||
| LastUpdateDate: | 01/31/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | NPP37705 | RI | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | APRN01266 | RI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | NPP37705 | 01 | RI | LICENSE NUMBER | OTHER |