Provider Demographics
NPI:1104102474
Name:MC LAIN, MICHELLE DEANE (APN)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:DEANE
Last Name:MC LAIN
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 MARINA CIR
Mailing Address - Street 2:
Mailing Address - City:CREAL SPRINGS
Mailing Address - State:IL
Mailing Address - Zip Code:62922-1411
Mailing Address - Country:US
Mailing Address - Phone:619-218-7158
Mailing Address - Fax:
Practice Address - Street 1:3333 W DEYOUNG ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959
Practice Address - Country:US
Practice Address - Phone:618-998-7947
Practice Address - Fax:618-998-7443
Is Sole Proprietor?:No
Enumeration Date:2011-10-31
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.009197363LA2200X
IL209009197363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health