Provider Demographics
NPI:1104068204
Name:FRESSOLA, MICHAEL (ACNP)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:FRESSOLA
Suffix:
Gender:M
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3623 S. FOREST AVENUE
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60513-1286
Mailing Address - Country:US
Mailing Address - Phone:708-485-9219
Mailing Address - Fax:708-485-2300
Practice Address - Street 1:3623 S. FOREST AVENUE
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:IL
Practice Address - Zip Code:60513-1286
Practice Address - Country:US
Practice Address - Phone:708-485-9219
Practice Address - Fax:708-485-2300
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-03
Last Update Date:2009-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209007505363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care