Provider Demographics
NPI:1588270615
Name:KILLIAN, MICHELLE RENEE (AGACNP)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:RENEE
Last Name:KILLIAN
Suffix:
Gender:F
Credentials:AGACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3079 N STATE ROAD 75
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:IN
Mailing Address - Zip Code:46917-9309
Mailing Address - Country:US
Mailing Address - Phone:765-430-7658
Mailing Address - Fax:
Practice Address - Street 1:3505 S REED RD
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-3838
Practice Address - Country:US
Practice Address - Phone:765-453-8666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-23
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28224359A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty