Provider Demographics
NPI:1063700276
Name:FAULL, MICHELLE S (DO)
Entity type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:S
Last Name:FAULL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 22ND AVE
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:WI
Mailing Address - Zip Code:53566-1569
Mailing Address - Country:US
Mailing Address - Phone:608-324-2000
Mailing Address - Fax:608-324-1246
Practice Address - Street 1:515 22ND AVE
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WI
Practice Address - Zip Code:53566-1569
Practice Address - Country:US
Practice Address - Phone:608-324-2000
Practice Address - Fax:608-324-1246
Is Sole Proprietor?:No
Enumeration Date:2011-07-21
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI56935-21208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation