Provider Demographics
NPI:1316349665
Name:MICHALAK, JILL
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:MICHALAK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5871 MONCLOVA RD
Mailing Address - Street 2:
Mailing Address - City:MAUMEE
Mailing Address - State:OH
Mailing Address - Zip Code:43537-1839
Mailing Address - Country:US
Mailing Address - Phone:198-978-3764
Mailing Address - Fax:419-887-8789
Practice Address - Street 1:5871 MONCLOVA RD
Practice Address - Street 2:
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537-1839
Practice Address - Country:US
Practice Address - Phone:419-897-8376
Practice Address - Fax:419-887-8789
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-18
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN249642163WW0000X
OHCOA.15618-NP363LF0000X
OHAPRN.CNP.15618363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WW0000XNursing Service ProvidersRegistered NurseWound Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0118302Medicaid