Provider Demographics
NPI:1427640986
Name:MILLWOOD, MICHELE ERICA
Entity type:Individual
Prefix:MRS
First Name:MICHELE
Middle Name:ERICA
Last Name:MILLWOOD
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 1:456 DERBY RD
Mailing Address - Street 2:
Mailing Address - City:BALDWIN
Mailing Address - State:NY
Mailing Address - Zip Code:11510-3063
Mailing Address - Country:US
Mailing Address - Phone:516-644-8563
Mailing Address - Fax:
Practice Address - Street 1:456 DERBY RD
Practice Address - Street 2:
Practice Address - City:BALDWIN
Practice Address - State:NY
Practice Address - Zip Code:11510-3063
Practice Address - Country:US
Practice Address - Phone:516-644-8563
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-05
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY440578163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05Medicaid