Provider Demographics
NPI:1104113893
Name:MICHEL, BRENDA L (FNP-BC)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:L
Last Name:MICHEL
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:BRENDA
Other - Middle Name:L
Other - Last Name:HAUPT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 19636
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9636
Mailing Address - Country:US
Mailing Address - Phone:217-545-3821
Mailing Address - Fax:217-545-4485
Practice Address - Street 1:751 N RUTLEDGE ST
Practice Address - Street 2:SUITE 2300
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-4968
Practice Address - Country:US
Practice Address - Phone:217-545-3821
Practice Address - Fax:217-545-4485
Is Sole Proprietor?:No
Enumeration Date:2011-07-01
Last Update Date:2011-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-008725363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$001Medicaid
IL522000019Medicare PIN