Provider Demographics
NPI:1730841370
Name:KING, MICHELLE LEE (APRN)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LEE
Last Name:KING
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 GLENDA CT
Mailing Address - Street 2:
Mailing Address - City:SANDWICH
Mailing Address - State:IL
Mailing Address - Zip Code:60548-9351
Mailing Address - Country:US
Mailing Address - Phone:815-530-3718
Mailing Address - Fax:
Practice Address - Street 1:8940 N WOOD SAGE RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-7822
Practice Address - Country:US
Practice Address - Phone:092-433-6103
Practice Address - Fax:309-243-3274
Is Sole Proprietor?:No
Enumeration Date:2021-10-12
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209024729363L00000X
IL2021039311363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily