Provider Demographics
NPI:1215062617
Name:MATTICE DANCER, MICHELLE M (MS, CNM, RN)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:M
Last Name:MATTICE DANCER
Suffix:
Gender:F
Credentials:MS, CNM, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11785 MORRISON MIKESELL RD
Mailing Address - Street 2:
Mailing Address - City:NEW PARIS
Mailing Address - State:OH
Mailing Address - Zip Code:45347-9214
Mailing Address - Country:US
Mailing Address - Phone:937-437-0444
Mailing Address - Fax:
Practice Address - Street 1:11785 MORRISON MIKESELL RD
Practice Address - Street 2:
Practice Address - City:NEW PARIS
Practice Address - State:OH
Practice Address - Zip Code:45347-9214
Practice Address - Country:US
Practice Address - Phone:937-437-0444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN 270174163W00000X
IN28136314A163W00000X
IN09000105A176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered163W00000XNursing Service ProvidersRegistered Nurse
Not Answered176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2703284Medicaid