Provider Demographics
NPI:1902107659
Name:JENSEN, MICHELLE LYNN (CRNA)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LYNN
Last Name:JENSEN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1929 EVA RD
Mailing Address - Street 2:APT 37
Mailing Address - City:KRONENWETTER
Mailing Address - State:WI
Mailing Address - Zip Code:54455-7110
Mailing Address - Country:US
Mailing Address - Phone:612-210-4502
Mailing Address - Fax:
Practice Address - Street 1:1929 EVA RD
Practice Address - Street 2:APT 37
Practice Address - City:KRONENWETTER
Practice Address - State:WI
Practice Address - Zip Code:54455-7110
Practice Address - Country:US
Practice Address - Phone:612-210-4502
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-11
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 142451-7367500000X
WI162146367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered