Provider Demographics
NPI:1962689406
Name:TAVENER, MICHELLE D (APN)
Entity type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:D
Last Name:TAVENER
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5437 KIETZKE LN
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89511-1088
Mailing Address - Country:US
Mailing Address - Phone:775-322-4550
Mailing Address - Fax:775-322-4956
Practice Address - Street 1:5437 KIETZKE LN
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89511-1088
Practice Address - Country:US
Practice Address - Phone:775-322-4550
Practice Address - Fax:755-322-4956
Is Sole Proprietor?:No
Enumeration Date:2008-01-28
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVAPRN000957363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV12200330OtherCAQH