Basic Information
| Provider Information | |||||||||
| NPI: | 1770926909 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NEICE | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CASSIDY | ||||||||
| OtherFirstName: | MICHELLE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 111 S 5TH ST | ||||||||
| Address2: | |||||||||
| City: | DOUGLAS | ||||||||
| State: | WY | ||||||||
| PostalCode: | 826332434 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073582122 | ||||||||
| FaxNumber: | 3073583432 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 E CENTER ST | ||||||||
| Address2: | |||||||||
| City: | DOUGLAS | ||||||||
| State: | WY | ||||||||
| PostalCode: | 826332446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073587300 | ||||||||
| FaxNumber: | 3073580831 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2013 | ||||||||
| LastUpdateDate: | 02/18/2019 | ||||||||
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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 | 207R00000X | 11935A | WY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 11935A | 01 | WY | STATE MEDICAL LICENSE | OTHER |