Provider Demographics
NPI:1366598823
Name:MINDHAM, MICHELLE M (APNP)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:M
Last Name:MINDHAM
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:903 BROADMOORE DR
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:WI
Mailing Address - Zip Code:53027-2701
Mailing Address - Country:US
Mailing Address - Phone:414-438-0919
Mailing Address - Fax:
Practice Address - Street 1:N65W24838 MAIN ST
Practice Address - Street 2:UNIT 400
Practice Address - City:SUSSEX
Practice Address - State:WI
Practice Address - Zip Code:53089-2670
Practice Address - Country:US
Practice Address - Phone:262-246-6822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2675-033363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIMM1308762OtherDEA REGISTRATION