Provider Demographics
NPI:1063955193
Name:BERNARD, MICHELE D
Entity type:Individual
Prefix:MRS
First Name:MICHELE
Middle Name:D
Last Name:BERNARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:191 LALUE
Mailing Address - Street 2:
Mailing Address - City:PORT AU PRINCE
Mailing Address - State:DELMAS
Mailing Address - Zip Code:WI
Mailing Address - Country:HT
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:929 CENTENNIAL AVE
Practice Address - Street 2:
Practice Address - City:NORTH BALDWIN
Practice Address - State:NY
Practice Address - Zip Code:11510-1916
Practice Address - Country:US
Practice Address - Phone:516-717-8240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-21
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY580468-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY$$$$$$$$$AMedicaid