Provider Demographics
NPI:1215939616
Name:LOWER, MICHELLE DIANE (CRNA)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:DIANE
Last Name:LOWER
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:PO BOX 1329
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47402-1329
Mailing Address - Country:US
Mailing Address - Phone:812-353-9816
Mailing Address - Fax:812-275-1381
Practice Address - Street 1:2900 W 16TH STREET
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:IN
Practice Address - Zip Code:47421-3510
Practice Address - Country:US
Practice Address - Phone:812-275-1200
Practice Address - Fax:812-275-1231
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP3269552367500000X
IN28110239A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000718587OtherANTHEM
FL304779200Medicaid
IN200227820AMedicaid
Y0521AMedicare PIN
IN200227820AMedicaid
IN940070HDMedicare PIN