Provider Demographics
NPI:1902439482
Name:REROMA, MICHELLE ANNE
Entity Type:Individual
Prefix:
First Name:MICHELLE ANNE
Middle Name:
Last Name:REROMA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13340 MORNING MIST PL
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60585-1318
Mailing Address - Country:US
Mailing Address - Phone:630-656-2973
Mailing Address - Fax:
Practice Address - Street 1:13340 MORNING MIST PL
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60585-1318
Practice Address - Country:US
Practice Address - Phone:630-656-2973
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-13
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070020523261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy