Provider Demographics
NPI:1699862722
Name:ZIMMERMAN, MICHELLE (NP)
Entity type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:
Last Name:ZIMMERMAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4591
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70606-4591
Mailing Address - Country:US
Mailing Address - Phone:337-310-7378
Mailing Address - Fax:337-310-7382
Practice Address - Street 1:4820 LAKE ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-6010
Practice Address - Country:US
Practice Address - Phone:337-310-7378
Practice Address - Fax:337-310-7382
Is Sole Proprietor?:No
Enumeration Date:2006-10-09
Last Update Date:2009-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA91959-3795363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1034002Medicaid
P55624Medicare UPIN
LA4C176Medicare PIN