Provider Demographics
NPI:1396348355
Name:HIESTAND, MICHELLE R
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:R
Last Name:HIESTAND
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 1:1092 DONALD DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45331-2545
Mailing Address - Country:US
Mailing Address - Phone:937-569-1578
Mailing Address - Fax:
Practice Address - Street 1:1092 DONALD DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:OH
Practice Address - Zip Code:45331-2545
Practice Address - Country:US
Practice Address - Phone:937-569-1578
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-20
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH261QA0600X
347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care