Basic Information
| Provider Information | |||||||||
| NPI: | 1881809275 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VANDERBILT | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 JOHN Q HAMMONS DR STE 400 | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537171967 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6084102700 | ||||||||
| FaxNumber: | 6084102901 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 JOHN Q HAMMONS DR STE 400 | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537171967 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6084102700 | ||||||||
| FaxNumber: | 6084102901 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2007 | ||||||||
| LastUpdateDate: | 12/15/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 2372-033 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 1881809275 | 05 | WI | MEDICAID |