Provider Demographics
NPI:1699869495
Name:CASSELL, MICHELLE R (CNS)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:R
Last Name:CASSELL
Suffix:
Gender:F
Credentials:CNS
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 26666
Mailing Address - Street 2:PHS PROVIDER ENROLLMENT
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6666
Mailing Address - Country:US
Mailing Address - Phone:505-923-5356
Mailing Address - Fax:505-923-5354
Practice Address - Street 1:PHS WOUND CLINIC
Practice Address - Street 2:5901 HARPER DRIVE NE
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109
Practice Address - Country:US
Practice Address - Phone:505-823-8870
Practice Address - Fax:505-823-8875
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2009-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR31349364SA2200X, 163WX1500X, 163WW0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
No163WX1500XNursing Service ProvidersRegistered NurseOstomy Care
No163WW0000XNursing Service ProvidersRegistered NurseWound Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM20372221Medicaid
N/AMedicare PIN
NM20372221Medicaid