Provider Demographics
NPI:1700271459
Name:FRESE, MICHELE R (APN)
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:R
Last Name:FRESE
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:MICHELE
Other - Middle Name:R
Other - Last Name:NIELSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APN
Mailing Address - Street 1:PO BOX 6037
Mailing Address - Street 2:
Mailing Address - City:WAUCONDA
Mailing Address - State:IL
Mailing Address - Zip Code:60084-6037
Mailing Address - Country:US
Mailing Address - Phone:847-526-2151
Mailing Address - Fax:847-526-2017
Practice Address - Street 1:431 W LIBERTY ST
Practice Address - Street 2:
Practice Address - City:WAUCONDA
Practice Address - State:IL
Practice Address - Zip Code:60084-2452
Practice Address - Country:US
Practice Address - Phone:847-526-2151
Practice Address - Fax:847-526-2017
Is Sole Proprietor?:No
Enumeration Date:2015-03-31
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209012687363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily