Provider Demographics
NPI:1154626240
Name:GAUDREAU, MICHELLE RENE'E (CRNA)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RENE'E
Last Name:GAUDREAU
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:602 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-2220
Mailing Address - Country:US
Mailing Address - Phone:231-348-2795
Mailing Address - Fax:231-348-2031
Practice Address - Street 1:416 CONNABLE AVE
Practice Address - Street 2:
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-2212
Practice Address - Country:US
Practice Address - Phone:231-348-2795
Practice Address - Fax:231-348-2031
Is Sole Proprietor?:No
Enumeration Date:2011-01-20
Last Update Date:2011-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704216895367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered