Provider Demographics
NPI:1306470851
Name:RICHMOND, MICHELLE A (AG-PCNP)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:A
Last Name:RICHMOND
Suffix:
Gender:F
Credentials:AG-PCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1440 W DUNKERTON RD
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50703-9648
Mailing Address - Country:US
Mailing Address - Phone:319-291-2455
Mailing Address - Fax:319-291-2464
Practice Address - Street 1:1440 W DUNKERTON RD
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50703-9648
Practice Address - Country:US
Practice Address - Phone:319-291-2455
Practice Address - Fax:319-291-2464
Is Sole Proprietor?:No
Enumeration Date:2020-02-24
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAAG02200055363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology