Provider Demographics
NPI:1588895783
Name:GAUTHIER, MICHELLE SARA (APRN)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:SARA
Last Name:GAUTHIER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:SARA
Other - Last Name:COUTTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:635 MAIN ST
Mailing Address - Street 2:ATTN: CREDENTIALING DPT
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-2718
Mailing Address - Country:US
Mailing Address - Phone:860-347-6971
Mailing Address - Fax:860-638-6601
Practice Address - Street 1:134 STATE ST
Practice Address - Street 2:
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06450-3293
Practice Address - Country:US
Practice Address - Phone:203-237-2229
Practice Address - Fax:203-686-1677
Is Sole Proprietor?:No
Enumeration Date:2009-08-05
Last Update Date:2012-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004220364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004236338Medicaid