Provider Demographics
NPI:1699151175
Name:JEAN, MICHAELLE
Entity type:Individual
Prefix:
First Name:MICHAELLE
Middle Name:
Last Name:JEAN
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 1:229 ROUTE 202 APT 2G
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:NY
Mailing Address - Zip Code:10970-2600
Mailing Address - Country:US
Mailing Address - Phone:845-746-3271
Mailing Address - Fax:
Practice Address - Street 1:229 ROUTE 202 APT 2G
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:NY
Practice Address - Zip Code:10970-2600
Practice Address - Country:US
Practice Address - Phone:845-746-3271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-06
Last Update Date:2015-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY317703-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0129070623Medicaid
1234567890OtherMEDICAID , MEDICARE
NY0129070623Medicare PIN
NY0129070623Medicaid
0129070623Medicare Oscar/Certification