Provider Demographics
NPI:1487802294
Name:RICHARDS, MICHELLE DAWN (LPN)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:DAWN
Last Name:RICHARDS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:DAWN
Other - Last Name:GUSTAFSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:415 N 7TH ST
Mailing Address - Street 2:
Mailing Address - City:LOUP CITY
Mailing Address - State:NE
Mailing Address - Zip Code:68853-8074
Mailing Address - Country:US
Mailing Address - Phone:308-382-3660
Mailing Address - Fax:308-385-2702
Practice Address - Street 1:2201 N BROADWELL AVE
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68803-2153
Practice Address - Country:US
Practice Address - Phone:308-382-3660
Practice Address - Fax:308-385-2790
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-04
Last Update Date:2008-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE17427164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse