Provider Demographics
NPI:1154987337
Name:SHOEN, MICHELLE ANNE
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:ANNE
Last Name:SHOEN
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:MICHELLE
Other - Middle Name:ANNE
Other - Last Name:WILDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6422 NUMBER FOUR ROAD
Mailing Address - Street 2:
Mailing Address - City:LOWVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13367-3220
Mailing Address - Country:US
Mailing Address - Phone:315-486-6179
Mailing Address - Fax:315-836-1207
Practice Address - Street 1:6422 NUMBER FOUR ROAD
Practice Address - Street 2:
Practice Address - City:LOWVILLE
Practice Address - State:NY
Practice Address - Zip Code:13367-3220
Practice Address - Country:US
Practice Address - Phone:315-486-6179
Practice Address - Fax:315-836-1207
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-14
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator