Provider Demographics
NPI:1942751664
Name:HARTNETT, MICHELLE MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MARIE
Last Name:HARTNETT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15300 WEST AVE # LL
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-4600
Mailing Address - Country:US
Mailing Address - Phone:708-923-5550
Mailing Address - Fax:708-226-2595
Practice Address - Street 1:636 RAYMOND DR STE 107
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563-9789
Practice Address - Country:US
Practice Address - Phone:630-359-8396
Practice Address - Fax:630-933-2729
Is Sole Proprietor?:No
Enumeration Date:2016-10-18
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.005991363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400369902OtherMEDICARE PTAN
IL$$$$$$$$$001Medicaid