Provider Demographics
NPI:1114528874
Name:WANDERING MICHELLE, LLC
Entity type:Organization
Organization Name:WANDERING MICHELLE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:C
Authorized Official - Last Name:DEFLORIMONTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-491-4478
Mailing Address - Street 1:4208 IDLEWILD DR
Mailing Address - Street 2:
Mailing Address - City:FRUITLAND PARK
Mailing Address - State:FL
Mailing Address - Zip Code:34731-5638
Mailing Address - Country:US
Mailing Address - Phone:407-491-4478
Mailing Address - Fax:
Practice Address - Street 1:4208 IDLEWILD DR
Practice Address - Street 2:
Practice Address - City:FRUITLAND PARK
Practice Address - State:FL
Practice Address - Zip Code:34731-5638
Practice Address - Country:US
Practice Address - Phone:407-491-4478
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-07
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
XD4688024OtherDEA