Provider Demographics
NPI:1174094072
Name:BANK, MICHELLE KAY (AGNP-C)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:KAY
Last Name:BANK
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12409 ROTH HILL DR
Mailing Address - Street 2:
Mailing Address - City:MARYLAND HEIGHTS
Mailing Address - State:MO
Mailing Address - Zip Code:63043-2941
Mailing Address - Country:US
Mailing Address - Phone:636-299-3632
Mailing Address - Fax:
Practice Address - Street 1:12409 ROTH HILL DR
Practice Address - Street 2:
Practice Address - City:MARYLAND HEIGHTS
Practice Address - State:MO
Practice Address - Zip Code:63043-2941
Practice Address - Country:US
Practice Address - Phone:636-299-3632
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-17
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOAG12180029363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology